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THE   PREVENTION   OF   DISEASE 


THE  PREVENTION   OF 
DISEASE 

TRANSLATED   FROM  THE  GERMAN 


WITH    AN     INTRODUCTION     BY 

H.   TIMBRELL    BULSTRODE,    M.A. 
M.D.  Cantab.  D.P.H. 

Medical  Department  of  H.  M.  I<ocal  Government  Board 

I<ecturer  on  Public  Health  in  the  Medical  School  of  Charing  Cross  Hospital 

Honorary  Secretary  and  Member  of  Council  of  the  Epidemiological 

Society  of  I,ondon,  etc. 


IN   TWO    VOLUMES 


VOLUME    I 


FUNK   &  WAGNALLS   COMPANY 

30  i,afaye;tte  pi<ace 

NEW  YORK 

1903 


Preface  to  the  English  Translation. 

It  has  been  the  endeavour  of  those  concerned  in  the  trans- 
lation of  this  work  to  render  the  meaning  of  the  original 
into  readable  English.  To  effect  this  it  has  in  many- 
places  been  found  necessary  to  break  up  into  convenient 
portions  the  lengthy  sentences  which  are  so  frequently  met 
with  in  German  scientific  literature,  but  which  are  alien  to 
English  ;  and  so  far  as  possible  the  presentment  of  German 
idioms  in  English  words  has  been  avoided.  Great  attention 
has  been  paid  to  rendering  the  scientific  terms  and  expres- 
sions by  their  correct  English  equivalents. 

Here  and  there  slight  omissions  have  been  made,  nearly 
always  for  the  purpose  of  abbreviation  or  condensation.  It 
has  not  however  been  deemed  advisable  to  modify  any  of 
the  statements  of  the  original,  although  there  must  neces- 
sarily be  numerous  points  on  which  there  is  room  for  two 
opinions. 

WILMOTT  EVANS. 


Introduction 

When  Messrs.  Archibald  Constable  &  Co.  told  me  of  their 
intention  to  publish  the  German  treatise  on  individual  pro- 
phylaxis, of  which  this  volume  is  a  translation,  and  invited 
me  to  introduce  it  to  the  profession  of  this  country,  I  had 
much  pleasure,  on  ascertaining  the  scope  of  the  work,  in 
complying  with  their  request. 

There  are  many  who  will,  I  think,  agree  that  the  term 
"  Preventive  Medicine"  is  employed  in  this  country  in  too 
restricted  a  sense  ;  that  its  application  to  preventive  action 
in  relation  to  certain  infectious  diseases  alone  is  practically 
a  misuse  of  the  expression. 

For  although  Preventive  Medicine  might  reasonably  be 
thought  of  as  dealing  with  infectious  diseases  generally,  it 
must  be  accepted  that  its  efforts  have  been  in  the  past,  and 
are  still,  mainly  directed  to  a  few  only  of  such  diseases. 

"When  indeed  we  have  made  mention  of  smallpox,  of 
scarlet,  typhus,  and  enteric  fevers,  of  diphtheria,  and  of  cer- 
tain exotic  diseases,  such  as  plague,  cholera,  and  yellow 
fever,  we  have  gone  far  to  exhaust  the  group  of  maladies 
with  which  Preventive  Medicine  is  wont,  as  a  matter  of  ac- 
tual practice,  to  directly  concern  itself. 

Although  professedly,  and  in  a  small  degree  in  practice, 
diseases  such  as  measles,  chicken-pox,  erysipelas,  puerperal 
fever,  and  infantile  diarrhoea  are  regarded  as  within  the 
sphere  of  influence  of  Preventive  Medicine,  it  cannot  be 
said  that  hitherto  any  very  comprehensive  attempts  have 
been  made  to  curtail  their  operations ;  and  it  is  only  quite 
recently  that  pulmonary  tuberculosis,  which  has  now  for 

vii 


INTRODUCTION 

manj^  years  been  regarded  as  communicable,  has  been  added 
to  the  diseases  concerning  which,  many  of  our  sanitary 
authorities  are  now  taking  action. 

With  respect  to  certain  other  diseases,  such  as  syphilis, 
the  communicability  of  which  has  long  since  been  estab- 
lished, which  are  responsible  for  much  impaired  health, 
organic  disease,  and  premature  death,  and  one  of  which 
maladies  is  but  too  easily  transmitted  from  parent  to  off- 
spring. Preventive  Medicine  in  G-reat  Britain  is  at  present 
silent.  Possibly  it  is  well,  seeing  the  ethical  and  con- 
troversial problems  involved,  that  this  passive  attitude 
towards  the  diseases  here  in  question  should  not  be 
suddenly  disturbed.  The  State  cannot,  perhaps,  move  in 
a  matter  such  as  this,  except  in  response  to  a  decisively 
expressed  pubHc  opinion ;  and  to  overload  the  machinery  of 
public  health  administration  with  unpopular  measures  is, 
as  has  been  amply  exemplified  in  the  history  of  public 
health,  a  futile  and  eminently  unscientific  proceeding.  In 
a  word.  State  Medicine  is  as  yet  in  its  infancy,  and  the 
near  future  has,  in  my  opinion,  enormous  developments  in 
store.  But  pending  any  collective  action  by  the  State, 
there  is  the  more  need  and  greater  scope  for  the  exercise 
of  prophylaxis  on  the  part  of  the  family  physician ;  indeed, 
whatever  attitude  the  State  may  in  the  immediate  or 
remote  future  adopt,  there  will,  it  seems  to  me,  be  a  grow- 
ing demand  for  the  services,  in  a  prophylactic  sense,  of  the 
medical  practitioner  ;  and  it  is  to  the  general  medical  prac- 
titioner that  this  work  is  mainly  addressed. 

It  has,  of  course,  to  be  borne  in  mind  that  Preventive 
Medicine,  in  its  direct  efforts  to  control  the  spread  and  to 
promote  the  extinction  of  certain  communicable  diseases, 
has  exerted,  and  is  exerting,  an  altogether  remarkable  effect 
upon  the  health  of  the  individual  and  of  the  community ; 
that  the  eminently  successful  efforts  of  public  hygiene  to 
provide  a  pure  and  plentiful  supply  of  water ;  adequate 
air-space  and  light  in  and  about  dwellings  ;  safe  and  in- 
offensive removal  of  sewage  and  refuse,  and  a  better  control 
of  our  foods  and  drinks,  is  producing  an  effect  which  is  felt 
quite  outside  a  limited  group  of  infectious  diseases. 

viii 


INTRODUCTION 

Moreover,  the  modern  tenour  of  factory  and  worksliop 
legislation,  as  also  of  measures,  such  as  the  Infants'  Life 
Protection  Act,  indicates  that  the  State  is  beginning  to 
accept  responsibilities,  qiid  the  health  of  the  individual, 
over  and  above  those  which  are  embraced  in  the  prevention 
of  infectious  disease  and  of  accidents. 

Still,  when  all  this  has  been  conceded,  it  will  prob- 
ably be  accepted  that  the  Legislature  as  such,  and  the 
sanitary  authorities  upon  whom  devolve  the  detailed 
application  of  the  Public  Health  Acts,  have  not  hitherto 
directly  concerned  themselves  with  the  rearing  of  a  healthy 
citizen,  save  in  so  far  as  they  have  endeavoured  to  prevent 
his  illness  from  certain  infectious  diseases,  and,  in  so  doing, 
have  materially  promoted  his  physical  welfare. 

Nor  can  it  be  said  that  outside  the  State  there  has  been 
any  very  serious  or  concerted  attempt  towards  founding  a 
science  of  individual  prophylaxis ;  an  omission  for  which 
the  public  rather  than  the  profession  is  responsible. 

The  medical  adviser  is  called  in  to  divert  complications 
and  death  where  disease  has  already  appeared ;  he  is 
but  rarely  consulted  as  to  the  manner  in  which  disease 
itself  may  be  prevented  from  crossing  the  threshold. 
Whether  or  not  it  is  true,  as  alleged,  that  the  Chinaman 
pays  his  physician  only  so  long  as  he  remains  well,  such 
a  custom  does  not  obtain  in  Europe.  And  yet  how  many 
are  there  who,  having  reached  middle  life,  cannot  appre- 
ciate how  much  better  their  physical  condition,  and  hence 
their  power  for  physical  and  mental  endurance,  might 
have  been,  had  they  been  looked  to  in  a  prophylactic  sense 
in  their  childhood  and  adolescence  ? 

Now  the  work  which  Messrs.  Archibald  Constable  &  Co. 
are  herewith  publishing  aims,  in  a  measure,  at  supplying 
this  omission.  Its  object  is  the  development  of  individual 
prophylaxis.  It  is,  as  far  as  I  am  aware,  the  first  attempt 
which  has  been  made  to  view  human  disease  in  its  entirety, 
whether  communicable  or  not,  from  the  standpoint  of 
Preventive  Medicine,  in  the  more  comprehensive  sense  of 
the  term. 

As  with  an  architectural  structure,  so  also  with  human 

ix 


INTEODUCTION 

diseases, we  obtain  different  and  fresh  impressions,  albeit  tbe 
structure  is  seen  over  and  over  again,  according  to  the  aspect 
from  "which  we  approach  it ;  and  the  sum  total  of  the  mul- 
tiple impressions  thus  received  makes  us  more  familiar  with 
the  edifice  as  a  whole. 

The  human  economy  has  been  repeatedly  approached, 
with  the  result  of  an  ever  increasing  knowledge,  from  the 
medical,  surgical,  pathological,  and  psychological  aspects, 
but  it  has  not,  save  in  an  altogether  too  restricted  sense, 
been  approached  from  the  view-point  of  the  prevention  of 
deterioration  and  disease. 

Professor  Martins,  who  contributes  to  this  volume  an 
admirable  chapter  on  General  Prophylaxis,  attempts  to 
differentiate  between  Hygiene  or  Public"  Health  and  Per- 
sonal or  Individual  Prophylaxis,  He  even  sees  antagonism 
of  principle  between  these  two  when  he  says,  "  Indeed  it 
cannot  be  denied  that  here  there  is  a  great  gulf,  a  dreadful 
contradiction,  between  the  aims  of  the  hygiene  of  the  in- 
dividual and  the  hygiene  of  the  race.  By  hygiene  as 
applied  to  an  individual  the  physician  strives  to  improve 
the  life  even  of  the  most  wretched  human  being,  and  his 
efforts  are  the  greater  the  more  feeble  is  the  individual ; 
but  the  hygiene  of  the  race  has  for  its  ultimate  aim 
pitilessly  to  eliminate  those  of  weakly  constitution,  and 
thus  improve  the  whole  people." 

But  here  Professor  Martins  is  voicing  a  broader  and  more 
evolutionary  conception  of  Preventive  Medicine  than  is 
understood  by  the  term  in  this  country. 

I  have  elsewhere^  stated  that  "  the  aim  of  Public  Health 
or  Preventive  Medicine  is  to  curtail  and,  if  possible,  prevent 
disease,  to  prolong  existence  and  to  render  life  happier  by 
means  of  improved  physical  conditions,"  and  I  fear  that 
even  in  this  definition  I  may  have  gone  further  than  some 
of  my  colleagues  in  the  Public  Health  Service  would  care 
to  go. 

But  Preventive  Medicine,  properly  understood  and  ap- 
plied, far  from  being  the  prerogative  of  a  special  branch  of 

^  Quain's  Dictionary  of  Medicine.  Third  Edition,  1902,  edited  by 
H.  Montague  Murray,  M.D.,  F.E.C.P.    Longmans,  Green  &  Co. 

-X 


INTRODUCTION 

the  profession,  must,  it  seems  to  me,  guide  our  action  in 
every  brancli,  and  perhaps  be  made  use  of  by  no  one  more 
than  by  the  medical  practitioner  or  family  physician.  He 
is  in  an  exceptionally  advantageous  position  to  recognise 
the  earliest  opportunity  for  the  application  of  prophylactic 
measures,  either  by  himself  or,  through  him,  by  those  who 
have  devoted  special  attention  to  one  or  another  organ  or 
system. 

Preventive  Medicine,  as  above  set  forth,  strives  to  pro- 
mote the  quality  as  well  as  the  quantity  of  human 
existence.  Its  highest  function  is  not  merely  to  prolong 
the  expectation  of  life,  but  to  enhance  the  sense  of  well- 
being  during  life. 

"We  have  not  here  in  England  concerned  ourselves  very 
seriously  with  what  is  likely  to  be  the  effect,  in  an 
evolutionary  sense,  of  Preventive  Medicine  upon  the  future 
of  the  race. 

Whether  or  not  the  perpetuation,  and  consequent  oppor- 
tunity for  propagation  of  the  physically  unfit  is  a  wise 
measure  from  an  evolutionary  standpoint  is  a  question 
which  hardly  calls  for  isolated  consideration.  Such  per- 
petuation is  inextricably  bound  up  with  the  improvement 
alike  of  the  relatively  fit  and  of  the  unfit ;  in  a  word,  with 
a  general  physical  improvement  of  those  now  inhabiting 
the  planet. 

Nature  alone  can  determine,  and  that  only  in  a  post- 
dated fashion,  who  are  the  fit  and  who  the  unfit. 

Moreover,  since  physical  evolution  would  appear,  as  far 
as  our  knowledge  of  it  goes,  to  be  bound  up,  or  to  be  at 
the  present  time  progressing  along  with,  a  moral  evolution 
which  attaches  more  and  more  importance  to  human  life 
and  well-being  ;  since,  too,  in  the  course  of  selective  action 
based  solely  upon  physical  qualities,  man  might  by  active 
interference  have  kept  back  from  existence  some  at  least 
of  those  who  have  enunciated  and  elaborated  this  very 
evolutionary  thesis,  we  may  perhaps  leave  these  remoter 
issues  to  natural  selection,  and  limit  our  horizon  to  the 
present  and  immediate  future. 

We  may  do  this  with  the  more  equanimity  since   this 

xi 


INTRODUCTION 

moral  evolution  of  wHcli  mention  has  been  made  would 
seem  to  be  tending  at  present  to  discourage  marriage 
unions  between  those  having  undesirable  physical  or 
mental  tendencies,  such  as  might,  through  marriage,  be- 
come accentuated  in  the  offspring. 

In  this  country,  however,  we  have  not  considered,  even 
ideally,  other  than  the  generations  living  or  immediately 
to  follow,  and  there  would  seem  therefore  to  be  no  anta- 
gonism in  principle  between  what  we  term  Preventive 
Medicine  and  what  is  spoken  of,  in  this  volume,  as  indi- 
vidual prophylaxis.  Each  is  an  accessory  to  the  other, 
or,  rather,  the  latter  is  a  branch  of  the  former ;  and  the 
operation  of  both  must  inevitably  promote  the  growth 
of  the  science  of  Preventive  Medicine,  and  enlarge  its 
sphere  of  general  utility. 

This  individual  medical  prophylaxis  is,  again  to  quote 
Professor  Martins,  "  The  sum  total  of  medical  counsel  and 
rules  intended  to  protect  the  individual  against  disease. 
In  this  .sense  medical  prophylaxis  guides  the  individual 
through  the  entire  course  of  life,  from  the  cradle  to  the 
grave." 

It  is  one  of  the  functions  of  this  branch  of  medicine  to 
ascertain  as  early  as  may  be  in  the  existence  of  the  indi- 
vidual, and  with  the  aid  which  the  life  history  of  his 
immediate  progenitors  can  afford,  what  is  the  predisposition 
of  that  individual  towards  any  given  "  pathological  re- 
action "  ;  and,  having  ascertained  such  tendency,  to  prevent 
its  operation.  Disease  is  not,  as  we  are  reminded  by  one 
of  the  contributors  to  this  volume,  a  "  thing,"  but  the 
resultant  of  many  factors,  the  working  together  of  which 
alone  constitutes  disease  ;  and  one  of  the  best  uses  to  which 
the  public  can  put  medical  science  is  to  seek  its  aid  towards 
preventing  the  co-operation  of  the  several  factors  involved. 

Dr.  Rosen  simply  and  aptly  illustrates  the  goal  of  indi- 
vidual prophylaxis  when  he  remarks,  "  The  physician 
ought  not  to  wait  until  he  discovers  an  impaired  note  at 
the  apex  of  the  lung,  or  hears  rales,  or  till  the  discovery  of 
tubercle  bacilli  with  the  microscope  makes  the  suspected 
diagnosis  of   tuberculosis  a   certainty,  before  he  begins  to 

xii 


INTRODUCTION 

treat  tlie  patient  hygienically  and  dietetically  " ;  and  Profes- 
sor Martins  expresses  the  same  idea  in  saying  tliat  ''  To 
bring  np  a  weakly  child  who  may  be  hereditarily  tainted, 
so  that  it  does  not  succumb  to  the  threatening  danger  of 
tuberculous  infection  is  individual  medical  prophylaxis," 

So,  too,  Professor  Mendelsohn,  of  Berlin,  who  contributes 
to  this  treatise  the  section  on  the  prevention  of  diseases  of 
the  heart,  will  appeal  to  his  readers  when  he  insists  that 
"  a  truly  scientific  prophylaxis  of  heart  disease  can  only 
be  carried  out  by  the  physician  who  makes  a  functional 
diagnosis,  not  an  anatomical  one.  It  is  not  enough  merely 
to  auscultate  and  percuss,  and  when  nothing  abnormal  has 
been  detected  by  this  procedure  to  conclude  that  special 
prophylactic  measures  are  unnecessary.  Even  when  there 
is  no  such  organic  abnormality  present  in  the  heart,  its 
condition  and  functional  capacity  should  be  determined  in 
every  possible  position  of  the  body — when  sitting,  when 
standing,  when  lying  at  rest  and  after  different  degrees  of 
bodily  exertion." 

This  endeavour  to  found  a  science  of  general  prophylaxis 
may  be  regarded  as  an  expression  of  the  claim  of  the  indivi- 
dual to  be  studied,  and  treated,  with  a  due  consideration  for 
his  tendencies,  bents,  or  "  idiosyncrasies,"  whether  these  are 
due  to  hereditary  transmission  or  not.  He  asks  that  he 
may  not,  without  due  inquiry,  be  forced  into  the  "average" 
mould  in  the  matter  of  drugs,  education,  or  employment ;  that 
the  "  personal  equation  "  may  be  made  a  note  of  as  early  in 
life  as  possible,  and  that  his  anatomical  and  functional 
capacity  may  be  had  regard  to  in  the  consideration  of  any 
questions  likely  to  involve  his  health  or  well-being.  Clearly, 
considerations  of  treatment  cannot  be  altogether  separated 
from  those  of  prevention.  All  treatment  is  in  a  certain 
sense  preventive  in  action,  whether  its  aim  be  to  avert 
complications,  further  deterioration,  or  actual  death ;  and 
what  may  be  termed  prophylactic  therapeutics  will  be 
found  duly  treated  of  in  the  present  work.  Although,  as 
Dr.  "Windscheid  has  it,  "  against  old  age  there  is  no  pro- 
phylaxis," we  can,  by  well-regulated  preventive  action  post- 
pone the  death  which  seems  the  inevitable  penalty  of  birth. 

xiii 


INTRODUCTION 

It  is  impracticable  in  an  introduction  sncli  as  this  to  con- 
vey an  adequate  idea  of  the  precise  scope  of  the  present 
■work,  which  extends  over  nearly  1,000  pages,  and  a 
brief  indication  of  the  ground  it  covers  can  alone  be 
attempted.  The  volume  opens  with  a  section  by  Dr.  Grold- 
schmidt,  dealing  with  the  principles  of  the  prevention  of 
disease,  and  furnishing  a  short,  and  highly  instructive, 
survey  of  the  prophylactic  methods  in  vogue  among  the 
Hindus  and  Chinese,  the  Israelites,  Egyptians,  Assyrians, 
and  others.  This  is  followed  by  a  historical  sketch  of 
the  growth  of  general  preventive  measures,  such  as  the 
provision  of  public  water  supplies,  refuse  disposal,  etc. ;  and 
under  this  section  there  is  an  interesting  account  of  the 
gradual  development  of  the  prophylactic  idea  in  respect  of 
the  control  and  examination  of  meat,  more  particularly  in 
Grermany.  It  will  be  well  that  some  of  our  lethargic  local 
sanitary  authorities  shall  learn  that  in  Augsburg,  as  early 
as  1276,  the  slaughter  of  cattle  was  prohibited  except  in 
slaughter  houses,  and  that  in  1716,  in  Hanover,  it  was 
ordained  that  all  cattle  should  be  examined  while  still 
alive,  and  that,  if  healthy,  a  mark  should  be  branded  upon 
their  horns. 

After  a  historical  account  of  the  prevention  of  Epidemic 
Diseases,  we  come  to  what  has  to  be  regarded  as  the  special 
feature  of  the  work,  which  is  prefaced  by  the  highly  in- 
teresting article  on  "  General  Prophylaxis,"  by  Professor 
Martins,  to  which  we  have  already  referred. 

Thereafter  the  several  contributors  treat  systematically  of 
the  separate  organs,  systems,  or  tissues  of  the  body. 

Throughout  each  section  there  is  brought  home  to  the 
reader  the  scope  which  exists  for  preventive  operations,  and 
he  seems  to  realize  the  very  contracted  character  of  our 
present  day  conceptions  and  practices  in  respect  of  pre- 
ventive action. 

Whether  he  reads  the  section  on  prophylaxis  in  surgery, 
in  midwifery,  in  the  diseases  of  children,  in  those  of  the 
eye,  ear  or  teeth,  or  whether  he  surveys  the  field  of  pro- 
phylaxis in  diseases  of  the  generative  and  urinary  organs, 
the  results  are  the  same.     The  need  for  greater  and  more 

xiv 


INTRODUCTION 

continuous  medical  supervision,  a  supervision  which  can,  at 
any  rate  in  the  first  instance,  be  most  usefully  exercised  by 
the  family  physician,  is  unconsciously  brought  home  to 
him  ;  and  the  conclusion  at  which  he  arrives  is  that  the 
development  of  this  prophylactic  idea  is  calculated  to  pro- 
mote the  progress  of  public  health  and  lead  to  a  better 
recognition  by  the  public  of  medical  advice  and  guidance. 
If,  indeed,  advances  were  made  even  in  the  single  direction 
of  appointing  medical  ofificers  to  schools  who  should  periodi- 
cally test  the  special  senses  of  the  school  children,  look  to 
their  teeth,  test  their  sight  and  hearing,  detect  existing 
or  threatening  deformities,  and  rediice  the  hours  of  work 
of  the  physically  and  mentally  unfit,  the  harvest  would 
speedily  be  so  abundant  that  further  action  in  a  similar 
direction  would  naturally  follow. 

Obviously,  in  a  work  such  as  this,  which  is  compiled  by 
many  writers,  there  are  some  divergencies  of  opinion,  more 
particularly  in  relation  to  those  diseases  for  which  the  world 
is  still  striving  for  a  prophylactic.  There  must  necessarily 
be  views  expressed  with  all  of  which  no  one  writer  can  be 
expected  to  entirely  agree,  and  upon  which  no  one  writer  is 
capable  of  expressing  an  opinion.  The  work  possesses  an 
additional  interest  in  that  it  was  written  in  the  first  in- 
stance for  the  profession  in  Grermany.  But  the  by  no 
means  easy  task  of  converting  German  into  readable  Eng- 
lish has  been  successfully  accomplished,  and  the  method  of 
treatment  throughout  is  original  and  exhaustive;  indeed, 
a  perusal  of  it  leaves  the  reader  with  a  clearer  conception 
of  the  multitudinous  bearings  of  diseased  conditions,  and 
furnishes  him  with  suggestions  which,  in  application, 
should  be  fraught  with  the  saving  of  many  lives  and  the 
prevention  of  much  disease  and  discomfort. 

In  conclusion,  I  venture  to  think  that  this  new  departure 
will  be  cordially  welcomed  by  the  profession ;  and  the  book 
may,  I  trust,  be  instrumental  in  laying  the  foundation  of  a 
systematic  individual  prophylaxis  in  this  country.  With 
the  rapid  growth  and  diffusion  of  knowledge  as  to  the  pre- 
vention of  disease,  the  physician  will  be  asked  in  an  ever 
increasing  degree  how  the  onset  of  certain  pathological  con- 

XV 


INTEODUCTION 

ditions  may  be  prevented ;  aud  although  he  may  not,  at 
present,  always  be  in  a  position  to  indicate  the  lines  which 
should  be  followed,  there  can,  I  think,  be  little  doubt  that 
the  subject  of  individual  prophylaxis  will  occupy  an  impor- 
tant place  in  medicine  in  the  near  future. 

H.   TIMBEELL  BULSTRODE. 


XVI 


CONTENTS 


Volume  I 


Introduction vii 

The  History  of   the  Prevention  of    Disease,  by  Dr.  S 

Goldschmidt,  of  Bad  Reichenhall    .         .         .         .  i 

General  Prophylaxis,  by  Professor  Martins,  of  Rostock  59 

77 

85 

97 

109 

137 


Internal  Diseases    ....... 

Diseases  of  the  Blood,  by  Dr.  Rosen    . 

Diseases  of  Metabolism,  by  Dr.  Rosen 

Infe(5tious  Diseases,  by  Dr.  Richard  Rosen   . 

Diseases  of  the  Leungs,  by  Dr.  Richard  Rosen 

Diseases  of  the  Heart,  by  Professor  Martin  Mendel- 
sohn, of  Berlin         .          .          .         .          .  .          -153 

Diseases  of  the  Digestive  Organs,  by  Dr.  Max  Einhorn, 
Professor  in  the  New^  York  Post-Oraduate  Medical 
School      .         .         .         .         .         .         .         .         .189 

Surgery,  by  Professor  A.  Hoffa,  of  Wiirzburg,  and  Dr. 

A.  Lilienfeld   .         .         .         .         .         .         .         .213 

Diseases  of  Women,  by  Dr.  O.  Schaeffer,  of  the  Uni- 
versity of  Heidelberg       .         .         .         .         .         -277 

Midwifery,    by    Dr.  O.  Schaeffer,  of   the  University  of 

Heidelberg       ........     337 

Diseases  of  Children,  by  Dr.  Rudolf  Fischl,  Lecfturer 
on  the  Diseases  of  Children  in  the  German  Uni- 
versity of  Prague    .......     407 


V 


'<\. 


CONTENTS 


Volume  II 


Disease  of  the  Nervous  System,  by  Dr.  Windscheid,  of 

the  University  of  Leipzig        .....     507 

Mental  Disease,  by  Dr.  Walter  Fuchs,  of  Emmendingen     565 

Diseases    of    the    Eye,   by    Professor    Konigshofer,    of 

Stuttgart  ........     631 

Disease  of  the  Ear,  by  Dr.  Albert  Bing,  of  the  Uni- 
versity of  Vienna    .         .         .         .         .         .         .     737 

Diseases  of  the  Teeth  and  Mouth,  by  Dr.  H.  Christian 

Greve,  of  Magdeburg      ......     767 

Diseases   of  the  Throat  and  Nose,  by  Dr.  Theodor  S. 

Flatau,  of  Berlin     .......     799 

Diseases  of  the  Urinary  Organs  and  of  the  Male  Gen- 
erative Organs,  by  Dr.  Albrecht  von  Notthafft,  of 
the  University  of  Munich,  and  Dr.  Arthur  Koll- 
mann,  of  the  University  of  Leipzig        .          .  .     843 

Venereal  Disease  and  Disease  of  the  Skin,  by  Dr.  Max 

Joseph,  of  Berlin     .  .          .          .  -931 

Index    .        . 987 


The  History  of  the  Prevention  of  Disease 

BY 

DR.    S.    GOLDSCHMIDT 

OF  BAD  REIOHENHALL 


The   History   of  the  Prevention 
of  Disease 

In  tracing  the  history  of  the  prevention  of  disease,  we  find 
that  the  measures  adopted  for  this  purpose  have  always 
followed  certain  lines,  which  often  run  parallel  one  with 
another,  though  various  races  at  different  times  have  given 
greater  prominence  to  some  one  of  these  than  to  the  rest. 
With  primitive  man  without  any  form  of  government 
the  prevention  of  disease  differed  but  little  from  that  which 
we  see  among  animals.  He  sought  probably  to  protect 
himself  against  changes  of  weather,  against  meteorological 
events,  against  hunger,  and  against  the  attacks  of  wild 
animals.  Among  nomadic  tribes  at  the  present  day 
prophylaxis  takes  the  form  of  contests  of  strength,  warlike 
performances  and  gymnastic  exercises.  But  they  have 
also  their  regulations  with  respect  to  food,  cleanliness,  and 
magic  rites  which  rest  upon  the  ancient  idea  of  the 
demonological  origin  of  disease.  Among  all  these  peoples 
we  find  certain  definite  customs  in  connexion  with  family 
events,  such  as  marriage,  the  birth  of  a  child  and  death. 
The  wearing  of  amulets  and  other  magic  charms  has  also 
originated  from  the  desire  to  guard  against  disease  and 
danger. 

We  shall  see  that  highly  civilized  peoples,  clinging  to 
the  conception  of  a  demonological  or  theological  causation 
of  disease  and  of  danger,  seek  to  protect  themselves  against 
these  just  as  uncivilized  races  do,  because  at  all  times  and 
among  all  races  there  exists  in  addition  to  the  scientific 
view  of  the  true  cause  of  disease,  also  the  opinion  that  dis- 
ease may  be  traced  to  supernatural  causes.     Religious  rites 

3 


THE  PREVENTION  OE   DISEASE 

whicli  have  been  handed  down  and  are  still  practised 
among  us  today  have  not  a  symbolical  meaning  only.  In 
the  opinion  of  the  people,  religious  ceremonies  are  concrete 
means  for  the  prevention  or  for  the  cure  of  disease.  If 
we  look  at  one  of  the  oldest  of  civilized  peoples,  the 
Hindus,  we  shall  find  the  conception  of  the  demon ological 
causation  of  disease  so  greatly  developed  and  so  conspicu- 
ously permeating  the  whole  life  of  this  unequally  gifted 
but  most  interesting  people,  that  the  history  of  prophylaxis 
would  be  incomplete  without  mention  of  their  customs. 

The  strengthening  of  the  body  and  cleanliness,  to  which 
even  nomadic  tribes  give  some  attention,  are  found  to  be 
considered  of  even  greater  importance  by  races  who  have 
settled  down  in  any  locality.  The  Grreeks  and  Romans 
practised  gymnastics  regularly.  Among  the  Greeks  these 
found  their  highest  expression  in  the  Olympian  games, 
and  gymnastic  exercises  were  resorted  to  not  only  for  the 
strengthening  of  the  body  for  war  but  also  probably  for 
its  aesthetic  development.  For  not  only  do  we  find  the 
m.en  exercising  their  bodies  in  order  to  be  able  effectively 
to  resist  an  enemy,  but  the  women  also  developed  their 
muscles  by  gymnastics  though  with  no  idea  of  taking  up 
arms  against  an  enemy.  The  bathing  and  anointing  of 
the  skin  and  washing  of  the  feet  after  journeys  were 
customs  among  all  ancient  races.  The  Egyptians  regarded 
cleanliness  in  the  light  of  a  divine  commandment.  The 
ruins  which  can  still  today  be  seen  of  magnificent  baths 
for  the  Greeks  and  Romans  testify  to  lavish  expenditure, 
both  municipal  and  private,  for  making  bodily  cleanliness 
j)Ossible  for  all  the  citizens.  Amongst  the  Hindus, 
Hebrews  and  Mohammedans  religion  requires  frequent 
ablutions  and  baths.  It  is  clear  that  all  these  hygienic 
rules  as  well  as  the  command  to  put  on  new  garments  on 
certain  occasions  have  also  a  symbolical  meaning.  Among 
those  nations  whose  religious  customs  are  closely  allied 
with  hygienic  and  dietetic  regulations,  it  is  difficult  to 
determine  which  was  the  primary  motive.  On  the  other 
hand,  as  a  contrast  to  these  hygienic  regulations,  we  find 
numerous  religious  ordinances  which  are  quite  opposed  to 

4 


THE  HISTORY   OF  THE   PREVENTION   OF  DISEASE 

the  principles  of  health.  Such  for  example  are  the  rules 
about  penance,  fasting  and  mortifying  the  body :  in  a 
word  the  absurd  regulations  of  asceticism,  which  sprang  up 
upon  the  fertile  soil  of  the  East  as  a  means  for  preventing 
to  some  extent  a  too  joyous  conception  of  life.  Unfortu- 
nately these  ascetic  practices  have  crept  into  the  civilization 
of  the  West  as  the  results  of  atavism. 

Among  all  races  it  was  customary  to  anoint  the  body 
after  the  bath.  The  anointing  was  often  associated  with  a 
kneading  of  the  body  which  had  a  beneficial  and  tonic 
effect,  and  which  has  recently  been  revived  as  a  thera- 
peutic agent  under  the  name  of  "  massage." 

Further  evidence  of  prophylactic  regulations  is  to  be 
seen  in  the  provision  made  for  the  water  supply  of  many 
ancient  towns.  Remains  of  aqueducts  and  conduits  have 
been  found  in  Egypt,  Assyria,  Greece  and  Rome,  the  latter 
in  such  a  good  state  of  preservation  that  it  has  recently 
been  possible  to  make  use  of  them  again.  The  knowledge 
that  many  diseases  may  be  caused  by  drinking  impure 
water  seems  therefore  to  date  back  very  far.  Hippocrates, 
the  father  of  medicine,  urgently  recommends  physicians  to 
test  drinking  water  carefully,  and  expressly  warns  them 
against  water  from  marshes  as  especially  dangerous  to 
health.  It  is  obvious  therefore  that  the  ancients  were  not 
indifferent  about  the  water  for  drinking  purposes,  and 
their  regulations  about  diet  show  an  even  more  strenuous 
endeavour  to  prevent  disease  which  may  be  caused  by  food. 
Among  the  Egyptians  and  the  Jews  we  find  clear  regula- 
tions about  food,  the  supervision  of  which  was  entrusted  to 
the  priest ;  this  will  again  be  referred  to  in  greater  detail 
in  a  special  section  relating  to  the  Israelites.  The  disposal 
of  the  excretions  of  the  body  and  of  other  impurities  also 
occupied  the  minds  of  ancient  civilized  nations.  The 
Cloaca  Maxima  of  Rome  is  the  most  impressive  of  these 
drainage  works  and  can  still  be  seen  today  in  action. 
Remnants  of  food  which  would  become  a  source  of  danger 
through  decomposition  were  destroyed  by  burning,  while 
the  excreta  of  human  beings  and  of  animals  generally  were 
drained  into  the  rivers.     Rules  for  the  disposal  of  the  dead, 

5 


THE   PREVENTION   OF  DISEASE 

whether  by  cremation,  as  among  the  Hindus,  Greeks  and 
Romans,  or  by  burial,  as  among  the  Israelites,  show  that 
the  object  was  to  remove  from  dwellings  these  sources  of 
disease  as  quickly  as  possible. 

Thirdly,  there  was  the  protection  against  epidemic  dis- 
eases. No  civilized  people  failed  to  recognize  the  difference 
between  infectious  diseases  and  the  other  groups  of  mala- 
dies. At  different  periods  of  history  we  find  sometimes  one 
infectious  disease  sometimes  another  most  prevalent. 
Smallpox  must  have  been  known  in  very  ancient  times, 
because  in  all  histories  of  medicine  we  find  mention  of 
inoculation  against  smallpox  among  the  Hindus  and 
Chinese  several  centuries  before  the  introduction  of  inocu- 
lation into  Europe.  But  both  in  antiquity  and  in  the  middle 
ages  no  disease  attracted  so  much  attention  as  bubonic 
plague  which,  known  sometimes  by  that  name,  sometimes 
as  the  "  Black  Death,"  decimated  the  towns  of  the  civilized 
world.  Since  the  first  thirty  years  of  the  nineteenth 
century  plague  has  only  reached  the  confines  of  civilized 
countries  but  has  not  penetrated  within  them.  Asiatic 
cholera  then  appeared  in  history  and  its  ravages  were  not 
less  than  those  of  plague.  Besides  such  pestilences,  which 
fortunately  appear  only  sporadically,  we  find  records  of 
leprosy  among  the  ancients  as  a  contagious  disease  which 
spread  far  and  wide  at  the  time  of  the  Crusades,  in 
Germany,  England,  Italy  and  France,  and  as  we  shall  see 
later  gave  rise  to  very  valuable  institutions.  Towards  the 
end  of  the  middle  ages,  at  about  the  beginning  of  the 
Reformation,  syphilis  seems  to  have  been  more  prevalent 
than  either  before  or  since.  We  must  consider  historically 
each  of  these  epidemics  in  turn  and  find  out  how  the  people 
tried  to  guard  against  them.  Our  plan  will  be  first  to 
consider  the  prophylactic  measures  adopted  by  the  various 
great  races  of  men.  Then  we  shall  take  a  retrospect  of  the 
various  general  preventive  measures  and  of  personal 
prophylaxis,  and  lastly  trace  out  the  historical  development 
of  the  prevention  of  the  different  epidemic  diseases. 


PART    I 

PEOPHYLAXIS  AMONG  THE  HINDUS 

We  have  already  referred  to  their  practice  of  inoculation 
against  smallpox.  There  was  also  a  sensible  regulation 
which  forbade  any  one  going  out  in  the  rain  unprotected. 
These  and  the  rules  about  washing  are  however  the  only 
ones  of  any  scientific  medical  interest  which  we  find  among 
the  Hindus,  all  others  are  the  outgrowth  of  fantastic 
demonology  and  superstition.  Disease  is  not  so  much 
regarded  as  a  punishment  sent  by  God  but  as  merely  the 
work  of  unfriendly  demons  which  must  be  counteracted  by 
antidotes  such  as  incantations,  strange  ceremonies  and 
exorcism.  Though  this  kind  of  prophylaxis  can  lay  claim 
to  no  medical  value,  yet  its  historical  significance  is  un- 
mistakable, and  even  today  among  Europeans  we  find 
superstitious  ideas  about  disease  and  its  prevention  which 
have  come  to  us  from  the  Hindus.  In  this  sketch  we 
shall  make  use  of  the  descriptions  given  by  Biihler  in 
his  very  thorough  work  Grundriss  indo-arischer  Philologie 
und  Altertumskunde^  Strasburg,  1897.  Unfortunately  the 
medical  part  of  this  work  is  not  yet  completed,  but  the 
third  volume  contains  sufficient  material  to  serve  our  pur- 
pose. 

The  child  begins  to  be  cared  for  even  before  he  is  born, 
in  fact  during  the  very  first  month  of  intra-uterine  life. 
By  prayers  and  sacrifices  the  sex  of  the  coming  child  is 
decided.  For  the  fourth  month  a  ceremony  is  prescribed 
to  prevent  miscarriage.  The  woman  moistens  her  right 
hand  and  passes  it  across  her  abdomen  above  the  navel 
three  times  while  repeating  certain  phrases.      This  cere- 

7 


THE  PREVENTION  OE  DISEASE 

mony  is  followed  by  the  garbharaksana,  for  the  preserva- 
tion of  the  embryo.  A  fruit  (sthalipaka)  is  boiled,  is 
offered  as  a  sacrifice  by  her  six  times,  and  afterwards  the 
mother's  abdomen  is  anointed  with  butter  while  certain 
words  are  recited. 

Preparation  is  made  for  delivery  (josantihoma)  by  select- 
ing a  room  in  which  it  is  to  take  place.  This  is  then 
anointed  or  fumigated  as  a  defence  against  evil  spirits 
(raksas).  As  soon  as  labour  pains  set  in  three  experienced 
women  are  called  in.  The  father  lights  a  fire,  scatters  it 
about,  offers  sacrifices  on  it,  and  then  besprinkles  the  woman 
in  labour  with  the  consecrated  elements.  In  other  castes 
he  pours  water  into  a  vessel  which  has  not  been  used  before 
and  besprinkles  the  woman  with  it,  he  places  a  turymti 
plant  at  her  feet  and  touches  the  head  or  body  of  the 
woman  with  it.  The  latter  is  moreover  often  stroked  in  a 
downward  direction.  Four  blades  of  munja,  with  their 
points  towards  the  east,  and  four  reeds  with  their  points 
towards  the  west  are  put  upon  her  head  and  form  a  kind 
of  oracle,  since  if  they  break  down  it  forebodes  danger 
to  her  life.  The  woman  is  washed  with  warm  water  from 
the  right  side  of  her  head  downwards  over  the  whole  body. 
To  ensure  a  normal  third  stage  of  labour  the  mother  is 
sprinkled  with  consecrated  water  after  the  birth  of  the 
child.  If  the  child  dies  directly  after  birth  certain  special 
ceremonies  are  performed,  but  these  are  not  of  any  interest 
in  connexion  with  our  subject. 

To  ensure  a  safe  puerperium  another  fire  is  immediately 
lighted  in  the  house  after  the  delivery  of  the  woman  and  is 
kept  alight  for  twelve  days.  The  newborn  child  is  held 
over  the  fire  while  herbs  are  burnt  in  it  for  fumigation. 
All  domestic  work  is  carried  out  by  the  light  from  this 
hearth.  Grains  of  mustard  seed  and  of  rice  are  used  for 
this  fumigation.  Curses  against  demons  are  uttered 
several  times  a  day  before  the  fire.  Every  time  after 
offering  sacrifice  the  father  washes  his  hands  and  recites 
a  poem.  Twelve  days  after  delivery  the  fire  is  put  out, 
mother  and  child  are  washed,  dressed  in  new  clothes,  and 
both  are  permitted  to  leave  the  lying-in  room. 


THE   HISTORY   OF   THE   PREVENTION   OF   DISEASE 

We  pass  by  the  consecration  ceremonies  performed  when 
the  hair  is  cut,  the  ears  pierced,  the  beard  shaved,  and  the 
child  goes  to  school —ceremonies  intended  to  frustrate  the 
malignity  of  impish  spirits.  The  marriage  ceremonies 
claim  our  attention.  An  important  and  sensible  rule  is, 
that  the  woman,  although  obliged  to  be  of  the  same  caste 
as  the  man,  must  not  be  related  to  him.  Certain  bodily 
marks  debar  from  marriage,  but  little  is  known  about 
the  subject,  and  they  seem  to  be  decided  by  oracle  rather 
than  by  any  examination. 

Before  the  Hindu  builds  a  house  he  must  thoroughly 
examine  the  site.  The  ground  must  not  contain  salt  and 
must  have  upon  it  no  plant  which  is  thorny  or  contains 
milky  fluid.  Certain  plants  must  be  found  only  in  certain 
aspects.  Thus  towards  the  east  there  must  be  no  as- 
vattha,  as  it  brings  danger  of  fire  to  the  house ;  towards 
the  south  no  paksa,  because  it  brings  illness  and  early 
death ;  towards  the  west  no  nyagradha,  because  it  brings 
with  it  fighting ;  towards  the  north  no  udumbarha, 
because  it  brings  disease  of  the  eyes. 

When  illness  arises  the  patient  should  dwell  in  the  east, 
north,  or  north-west  of  the  house  and  he  will  then  re- 
cover. 

We  shall  omit  the  complicated  customs  at  death  and 
merely  mention  that  children  who  have  died  under  two 
years  of  age  are  buried,  but  all  other  dead  bodies  are  burnt. 
But  previously  they  are  exposed  to  view  for  a  long  time. 
Those  who  have  taken  part  in  a  funeral  procession  must 
not  enter  their  houses  again  till  they  have  fulfilled  the 
strict  regulations  for  purification.  But  these  are  regula- 
tions which  have  to  do  with  mourning  rather  than  the 
prevention  of  disease.  The  house  in  which  any  one  has 
died  may  not  be  re-entered  for  three  to  fourteen  days, 
according  to  the  nature  of  the  fatal  illness.  To  prevent 
hereditary  disease  the  grave  must  be  kept  well  watered. 

As  there  are  certain  customs  and  ceremonies  for  the 
prevention  of  disease,  so  there  are  others  again  by  means 
of  which  the  disease  may  be  transferred  from  one  person 
to  another. 

9 


THE  PREVENTION   OF  DISEASE 

This  superstition  survives  in  tlie  *' jettatore  "  and  "  maloc- 
chio  "  of  Italians. 

The  regulations  which  we  have  described  were  not  only 
in  force  in  ancient  India  but  are  still  largely  practised  even 
at  the  present  day  by  this  highly  gifted  but  apathetic 
people  who  have  found  in  Buddhism  the  most  powerful 
expression  of  a  melancholy  conception  of  the  world.  It  is 
not  surprising  that  Hindus,  holding  these  views  about 
medicine  and  taiking  no  active  preventive  measures,  cannot 
rid  themselves  of  the  many  diseases  which  starting  thence 
often  spread  over  the  whole  world,  and  are  always  endemic 
in  India.  As  they  do  not  even  know  how  to  guard  against 
poisonous  reptiles  and  beasts  of  prey,  to  whom  about  40,000 
human  beings  fall  victim  every  year,  so  they  do  not  try 
to  protect  themselves  by  rational  methods  against  the  still 
greater  dangers  of  infective  disease.  The  reports  of  travel- 
lers that  the  Indian  jugglers  know  how  to  make  themselves 
immune  to  the  bites  of  poisonous  snakes  still  require  con- 
firmation. 

PKOPHYLAXIS  AMONG  THE  CHINESE » 

The  Chinese  have  no  native  religion,  and  no  priesthood 
and  no  church  except  those  which  have  been  imported 
from  other  nations.  Nevertheless  it  is  only  natural  that 
superstitious  beliefs  about  diseases,  their  treatment  and 
prevention,  should  have  crept  into  this  nation  with  its 
enormous  numbers  of  ignorant  people.  Yet  prophylaxis 
among  the  Chinese  is  more  of  the  nature  of  pedantic  rules 
which  have  sprung  from  absurd  conceptions  of  the  universe 
rather  than  from  demonology.  The  Chinese  are  thoroughly 
imbued  with  a  sense  of  loyalty.  They  know  nothing  of 
the  exclusive  caste  system  of  the  Hindus,  but  they  bow 
down  before  the  idea  of  rank  with  its  degrees,  and  see  in 
their  poor  mythological  conceptions  the  degrees  of  rank 
which  are  obvious  to  them  in  the  State.  Their  deities  are 
the  sun,  the  moon,  the  stars,  and  other  impressive  pheno- 

^  The  information  here  given  has  been  taken  from  Path's  work 
Religion  und  Kultur  der  Chinesen,  Munich,  1862. 

10 


THE  HISTORY  OF  THE   PREVENTION  OF  DISEASE 

mena  of  the  sky  and  the  earth.  There  is  a  spirit  of 
drought,  a  spirit  which  injures  horses,  a  spirit  which 
permits  poisonous  animals  to  exist,  and  they  appease  all 
these  spirits  by  many  kinds  of  sacrifices  of  little  value. 
According  to  the  severity  of  any  disease  it  is  referred  to . 
some  higher  or  lower  deity.  Occasionally  true  Shamanism 
is  met  with.  At  each  season  of  the  year  (and  the  Chinese 
have  five  seasons)  there  appears  an  inspector  of  the  districts, 
fung-siung-shi,  who  drives  away  the  diseases  peculiar  to 
that  season  ;  his  function  seems  however  to  be  exercised 
more  in  regard  to  the  diseases  of  plants  and  of  animals 
than  those  of  men.  He  appears  clad  in  the  skins  of  young 
bears,  has  four  eyes  of  yellow  metal  on  his  dress,  carries 
a  lance  and  shield,  and  is  accompanied  by  100  followers 
in  red  and  black  dresses.  In  the  spring  the  exorcist 
(Wa)  addresses  the  spirits  to  prevent  epidemics.  But  the 
real  prayer  against  disease  is  always  said  by  women — pray- 
ing women  (niutscho).  There  is  no  real  priesthood  among 
the  Chinese.  Proj^hesying,  for  which  the  tortoise  shell 
and  the  tsie  plant  are  used  as  an  oracle,  is  practised  by 
certain  men. 

The  market  regulations  introduced  by  Confucius  form  a 
collection  of  advice  rather  than  of  any  real  sanitary  rules. 
They  contain  warnings  against  the  produce  of  the  field 
when  not  in  season,  against  fruit  which  is  not  ripe,  against 
birds,  game,  fish,  which  have  not  been  killed  according  to 
direction.  Further,  raw  food  material  alone  must  be  offered 
for  sale,  but  no  prepared  food  or  beverage.  Lastly,  they 
exclude  from  the  market  all  animals  and  wine  which  have 
been  offered  in  sacrifice. 

A  better  understanding  of  hygiene  is  shown  in  their 
teaching  that  food  must  be  according  to  the  individual's 
age,  and  that  an  old  man  may  take  many  foods  which  are 
forbidden  to  the  young  man.  But  this  instruction  is  so 
arbitrary  that  it  loses  much  of  its  value  for  prophylaxis. 
The  Chinese  are  not  given  to  taking  alcohol.  Cultivation 
of  the  vine  was  introduced  late  into  China,  and  grapes  are 
always  eaten  as  fresh  fruit.  The  Chinese  make  an  intoxi- 
cating drink   from  rice.     The  injurious    effects    of    alcohol 

11 


THE  PREVENTION   OF   DISEASE 

seem  long  ago  to  have  been  known  and  it  is  only  permitted 
to  be  used  upon  special  occasions.  But  in  order  that  drink- 
ing might  be  reduced  to  the  most  moderate  quantities,  the 
ancient  emperors  ordered  this  beverage  to  be  drunk  only 
from  very  small  glasses,  and  that  100  obeisances  should  be 
made  before  drinking  another  such  portion.  Thus  a  small 
quantity  of  alcohol  takes  a  long  time  to  consume.  The 
following  regulations  about  food  are  for  the  most  part  com- 
pletely incomprehensible.  It  is  forbidden  to  eat  young 
fowls  and  turtle,  wolves  from  which  the  intestines  are 
missing,  dogs  without  their  kidneys,  foxes  with  the  back- 
bone missing  or  without  a  head  ;  rabbits  and  hares  which 
have  been  deprived  of  the  lower  portion  of  the  backbone ; 
sucking  pigs  in  which  the  brain  is  missing  ;  fish  without 
bones  ;  turtles  which  have  lost  one  shell. 

The  skin  and  sinews  of  slaughtered  animals  are  to  be 
thrown  away.  Fish  should  be  inspected  to  see  whether  it 
is  fresh  or  tainted.  Dates  must  be  fresh,  chestnuts  without 
maggots.  The  down  on  peaches  should  be  rubbed  off;  pears 
and  apples  should  be  bored  when  offered  for  sale. 

These  market  regulations  are  some  of  them  sensible, 
others  absurd.  Still  more  strange  are  the  following  warn- 
ings : — Oxen  which  low  at  night  have  stinking  flesh  ;  sheep 
with  thin  long  wool  smell  rank  ;  dogs  with  red  thighs 
have  rancid  fat ;  birds  with  fine  voice  and  shimmering 
(white)  feathers  have  putrid  flesh  ;  pigs  which  do  not  see 
well  and  whose  eyelids  stick  together  have  fatty  tumours  ; 
horses  with  black  back  and  fore-legs  have  stinking  flesh. 
The  following  preventive  regulations  sound  a  little  more 
sensible.  The  tail  of  chickens  when  narrow  and  full  should 
not  be  eaten,  nor  the  flesh  near  the  tail  of  the  wild  goose. 
The  meat  on  the  ribs  of  swans  and  owls  is  not  safe,  neither 
is  the  liver  of  the  fowl  nor  the  stomach  of  the  wild  goose 
and  stag.  Meat  to  be  eaten  should  be  tender.  From  this 
list  of  food  we  see  that  the  Chinese  in  general  are  not  par- 
ticular in  their  diet.  If  we  add  to  this  that  the  modern 
Chinese  despise  neither  rats  nor  moles  nor  snakes  as  food, 
the  above  laws  may  seem  absurd  but  are  nevertheless  in- 
tended to  restrict  him  in  his  appetite. 

12 


THE  HISTORY  OF  THE  PREVENTION  OF  DISEASE 

The  mode  of  thought  of  the  Chinese  in  reference  to 
spiritual  matters  affects  their  laws  about  food,  different 
kinds  of  which  are  special  to  certain  seasons.  The  Chinese 
recognize  five  elements  (wood,  fire,  earth,  metal  and  water), 
and  with  these  they  associate  five  fundamental  colours  and 
also  five  varieties  of  food,  one  for  each  season.  Further,  they 
distinguish  between  five  different  kinds  of  taste ;  and  the 
element,  the  season,  the  colour  and  the  taste  must  always 
agree.  In  the  spring,  which  corresponds  with  the  element 
wood  and  with  the  colour  green,  bitters  should  be 
eaten.  In  the  summer,  the  season  of  fire  and  of  red,  sweet 
foods  are  eaten.  The  season  between  summer  and  autumn 
corresponds  with  earth  and  the  colour  yellow,  and  things 
pungent  should  be  eaten.  Autumn  is  the  time  for  the 
colour  white  and  for  metals,  therefore  acid  things  should  be 
eaten.  Winter  is  the  season  of  water  and  of  black,  and 
then  salt  food  should  be  eaten. 

We  must  not  omit  the  hygienic  regulations  about  dwell- 
ings and  cleanliness,  though  here  too  there  are  no  obvious 
intelligible  reasons  for  them. 

The  doors  of  the  house  should  always  be  open.  The  head 
should  lie  towards  the  east.  If  an  inmate  becomes  ill  or  is 
overtaken  by  a  storm  he  should  change  his  position.  He 
gets  up  even  if  it  be  night,  dresses  and  puts  on  his  hat. 
The  body  must  be  washed  five  times  a  day,  each  part  of  the 
body  with  a  different  water  ;  the  head  and  face  should  be 
washed  with  millet  water.  After  a  bath,  different  dry 
towels  are  to  be  used  for  the  upper  and  for  the  lower  parts 
of  the  body.  Moreover  after  a  bath  the  Chinese  have  to 
lie  upon  a  mat  on  the  grass  and  drink  water.  Every  fifth 
day  children  are  admonished  to  take  warm  water  to  their 
parents  and  ask  to  be  bathed,  and  every  third  day  to  have 
the  head  washed.  If  the  face  is  very  dirty  rice  water 
may  be  used,  but  for  soiled  feet  hot  water  only  should  be 
used. 

It  is  curious  that  the  Chinese  who  do  not,  like  the 
inhabitants  of  India,  burn  corpses  but  cover  them  with 
a  little  earth  and  then  erect  a  mound  over  them,  do  not 
have   any  common  burial-ground.      Each  chooses   for   his 

13 


THE  PREVENTION  OF  DISEASE 

relatives  some  favourite  spot  outside  the  town,  and  on  fes- 
tival days  all  the  members  of  the  family  go  to  the  mound 
to  deck  it  with  flowers  and  possibly  pray  to  the  deceased. 
It  is  characteristic  that  the  Chinaman  according  to  his  rank 
addresses  a  special  deity,  and  it  would  be  a  punishable 
offence  against  etiquette  if  an  ordinary  citizen  were  to  ad- 
dress his  prayers  to  the  highest  deities,  the  sun  and  moon  ; 
the  ruler  however  must  address  these  deities  alone. 

From  the  above  it  is  evident  that  this  very  intelligent 
but  unimaginative  people  have  not  contributed  to  the  ad- 
vancement of  prophylaxis  and  of  medicine  any  more  than 
have  the  inhabitants  of  India.  And  thus,  though  China  is 
less  exposed  to  the  ravages  of  epidemics  than  the  neigh- 
bouring people,  yet  it  stands  powerless  against  certain 
results  which  follow  from  its  culture,  and  knows  no  method 
to  adopt  against  its  increasing  over-population  except  in- 
fanticide, artificial  abortion  and  extensive  emigration. 

PEOPHYLAXIS  AMONG  THE  ISEAELITES 

The  statement  frequently  made  that  the  Jews  are  a 
"  priestly  people  "  means  distinctly  that  some  of  the  laws 
which  were  intended  only  for  the  priesthood  in  Egypt,  were 
proclaimed  as  valid  for  all  the  people  by  Moses,  the  pupil  of 
Egyptian  priests.  It  is  remarkable  how  severely  any  breach 
of  hygienic  regulations  is  dealt  with.  The  severity  which 
threatens  with  death  the  breaking  of  what  often  appears 
to  us  some  trivial  dietetic  regulation  will  only  become  in- 
telligible if  we  look  at  the  historical  events  of  the  period 
when  these  laws  were  promulgated. 

The  Jews  were  a  rustic  people  and  very  few  in  numbers. 
Moreover  this  small  nation  had  not  only  to  till  a  very 
unfruitful  soil  but  also  to  be  prepared  for  constant  struggles 
with  neighbouring  tribes.  Under  these  circumstances  the 
preservation  of  each  individual  life  was  of  the  utmost  eco- 
nomic importance.  It  was  urgently  necessary  to  keep  up 
the  working  capacity  of  every  man  ;  whoever  therefore  did 
anything  which  would  injure  his  own  health  would  be 
committing  a   crime  against  the  general  welfare,  against 

14 


THE  HISTORY  OF  THE   PREVENTION   OF   DISEASE 

the  power  of  defence  and  the  power  of  work  of  the  whole 
nation.  This  affords  a  striking  contrast  to  the  inhabitants 
of  India  and  the  Chinese,  among  whom  over-popnlation  had 
given  rise  to  carelessness  in  regard  to  prophylaxis.  To  break 
the  rules  of  health  was  not  regarded  from  the  standpoint  of 
demonology  but  was  looked  upon  as  falling  away  from  God, 
as  a  sin  the  direct  consequence  of  which  was  punishment 
by  God.  The  theological  conception  seems  somewhat  strange 
to  our  modern  ideas,  but  compared  with  the  demonological 
conceptions  of  the  inhabitants  of  India  and  of  the  Chinese 
it  marks  a  very  great  advance.  The  Bible  recognizes  no 
demons,  and  we  find  in  it  no  suggestion  of  the  belief  in  a 
devil.  Man  himself  is  responsible  for  his  deeds,  and  though 
the  hard  law  "  Thy  sins  shall  be  visited  unto  the  third  and 
fourth  generations  "  does  not  conform  to  our  sense  of  justice, 
nevertheless  it  expresses  what  careful  observation  at  all 
events  shows  to  hold  good  for  medical  sins.  The  fact  that 
the  Jewish  race  still  exists,  though  no  longer  a  nation, 
though  their  national  life  lasted  scarcely  500  years,  and 
though  they  have  been  persecuted  and  hated  by  the  nations 
among  whom  they  have  been  scattered,  is  owing  in  no  small 
degree  to  the  scrupulous  way  in  which  they  have  carried 
out  the  biblical  laws  of  hygiene.  The  best  known  of  these 
hygienic  laws  refer  to  their  food.  Here  too  correct  obser- 
vation is  mixed  up  with  superstitious  ideas,  though  the 
latter  have  in  course  of  time  assumed  a  commonsense  mean- 
ing. The  law  that  the  blood  of  slaughtered  animals  shall 
be  drained  away  rests  upon  the  superstitious  idea  that  life 
has  its  origin  in  the  blood,  or  that  the  spirit  dwells  in  the 
blood.  Thence  has  arisen  the  dislike  which  the  orthodox 
Jew  even  at  the  present  day  feels  to  the  blood  of  animals. 
No  part  of  the  body  may  be  used  for  food  till  all  the  blood 
has  been  removed  by  salt  and  water.  Yet  in  spite  of  the 
superstitious  origin  of  the  custom,  it  is  nevertheless  a 
valuable  preventive  regulation  in  hot  countries.  Salt  is 
very  good  for  the  preservation  of  the  meat,  and  meat  de- 
prived of  its  blood  is  far  less  apt  to  decompose  than  meat 
which  still  contains  blood.  The  law  that  the  flesh  of  a 
slaughtered  animal  should  be  eaten  not  later  than  the  third 

15 


THE  PREVENTION   OF  DISEASE 

day,  and  if  not  eaten  then  mnst  be  burnt,  seems  a  very  sen- 
sible regulation  in  countries  where  putrefaction  sets  in 
extremely  rapidly.  The  Mosaic  law  forbids  the  eating  of 
the  flesh  of  certain  animals  as  being  unclean.  We  have 
seen  that  other  races  too  have  prejudices  against  eating 
certain  animals.  These  national  idiosyncrasies  are  not 
always  intelligible.  Yet  it  is  striking  that  there  is  no  race 
which  does  not  exclude  certain  animals  from  use  as  food, 
while  these  same  animals  are  eaten  by  other  nations.  There 
are  American  nomadic  tribes  who  eat  no  fish  ;  others  again 
who  have  a  prejudice  against  game.  Even  the  Chinese,  who 
eat  such  a  variety  of  food,  have,  as  we  have  seen,  laws  for- 
bidding the  use  of  some  foods.  Certain  Indian  castes  touch 
no  animal  food,  living  exclusively  upon  a  vegetarian  diet. 

The  Mosaic  Law  especially  forbids  the  eating  of  those 
animals  which  experience  has  taught  may  cause  disease  : 
such  as  the  flesh  of  swine,  of  cats,  and  of  certain  rodents, 
which  Luther  translates  "  rabbits,"'  but  which  probably  are 
"  rats.''  Recent  research  has  shown  that  these  animals  are 
apt  to  harbour  trichinae,  and  Yirchow  justly  pronounces 
Moses  one  of  the  greatest  of  physicians  of  all  time.  Animals 
leading  a  free  life  such  as  wild  animals  and  beasts  of  prey 
may  not  be  used  for  food,  partly  to  discourage  the  love  of 
hunting  which  the  Bible  regards  as  a  cruel  sport,  partly 
because  it  is  not  possible  to  control  the  food  of  such  animals, 
and  they  sometimes  eat  food  which  is  bad  and  which  might 
be  harmful  to  men.  Humane  feelings  for  animals  is  a 
reason  why  certain  animals'  flesh  is  forbidden  to  be  eaten. 
Thus  only  can  we  understand  why  it  is  forbidden  to  eat 
the  flesh  of  horses,  asses,  mules  and  camels,  which  have  been 
fed  by  man.  These  animals  are  so  useful  to  man  that  to 
use  them  for  food  is  opposed  to  the  tender  feelings  of  the 
biblical  lawgiver.  But  we  should  be  going  very  wide  of 
the  mark  if  we  thought  there  was  a  reason,  sanitary  or 
humane,  for  every  such  law.  For  example  it  is  quite 
incomprehensible  why  the  loins  should  not  be  fit  for  food 
till  the  iliac  vein  has  been  removed.  The  biblical  writer 
has  made  a  law  of  that  which  was  a  tradition  long  before 
the  Mosaic  period. 

16 


THE  HISTORY  OF   THE  PREVENTION  OF  DISEASE 

Ritual  circumcision  is  a  very  vexed  question.  This 
custom  was  observed  by  many  ancient  races,  and  it  is 
known  that  Mohammedans  practised  the  rite  long  before 
the  time  of  Mohammed.  Recent  historical  investigation 
shows  that  it  arose  out  of  a  heathen  worship,  the  worship 
of  Moloch.  Still  I  believe  we  ought  not  to  underrate  the 
sanitary  value  of  this  operation.  The  removal  of  the  prepuce 
prevents  the  collection  of  dirt,  and  the  uncovered  glans 
loses  much  of  its  vulnerability  in  course  of  time.  But 
systematic  data  to  prove  the  value  of  the  rite  are  hitherto 
wanting.  Moreover  the  raising  of  this  operation  into  a 
religious  act  was  certainly  not  of  Mosaic  origin.  It  is  much 
more  probable  that  Moses,  who  was  opposed  to  all  such 
heathen  barbarous  customs,  had  nothing  to  do  with  intro- 
ducing this  rite.  He  did  not  submit  his  own  son  to  circum- 
cision ;  but  the  boy  was  circumcised,  without  the  father's 
knowledge,  by  the  mother  when  the  boy  was  ill  in  the 
desert.  And  the  mother  was  the  daughter  of  the  heathen 
priest  Jethro.  Besides  these  hygienic  laws  stated  above, 
the  biblical  lawgiver  issued  other  regulations  which  cannot 
be  improved  upon  even  at  the  present  day.  He  gives  orders 
about  the  position  of  privies  :  these  are  to  be  outside  the 
encampment,  and  the  refuse  is  to  be  covered  with  earth. 
Most  exemplary  regulations  are  laid  down  about  the  life 
and  intercourse  between  husband  and  wife,  and  about  rest 
on  the  Sabbath. 

For  leprosy  modern  prophylaxis  can  add  nothing  to  the 
biblical  regulations.  A  leper  must  live  outside  the  camp 
and  must  not  frequent  public  places.  If  any  one  is  sus- 
pected of  having  leprosy,  he  is  isolated  for  seven  days  from 
the  members  of  the  community,  and  then  must  appear 
before  the  priest  who  examines  him.  If  no  suspicious  signs 
have  developed,  the  patient  is  to  be  kept  another  seven 
days  outside  the  camp.  "When  then  seen  for  the  third  time 
by  the  priest,  and  there  are  no  signs,  the  man  is  allowed  to 
rejoin  the  community,  but  his  clothes  are  burned  outside 
the  camp. 

Space  forbids  us  to  say  more ;  neither  is  it  necessary, 
because  the  hygiene  of  food  and  the  prophylaxis  in  the 

17  c 


THE  PREVENTION  OF  DISEASE 

Bible   have   already   been  described   at  length   by   many 
writers  (Baginsky,  Rabinowicz). 

Later  the  Talmud  concerned  itself  with  preventive  regu- 
lations for  the  Jews.  In  this  we  find  sensible  and  foolish  laws 
blended  together.  The  rules  about  slaughtering  animals 
must  be  pronounced  excellent  from  the  hygienic  point  of 
view,  and  we  shall  give  the  most  important  of  them.  For 
this  unavoidable  and  cruel  act  the  slaughterman  must  take 
care  to  use  a  very  sharp  knife  without  any  notches  in  it, 
and  should  kill  the  animal  with  one  cut,  and  this  cut 
should  pass  through  the  neck  as  far  as  the  vertebral  column. 
This  fulfils  too  the  hygienic  requisite  of  letting  the  blood 
flow  out  quickly,  because  this  cut  will  sever  the  largest 
vessels  which  convey  blood  to  and  from  the  head.  The 
subsequent  washing  with  salt  and  water  is  also  thereby 
made  easier.  After  the  animal  is  killed  it  must  be  in- 
spected. And  then  the  signs  of  disease  are  described  so 
well  that  this  description  of  the  signs  must  have  had  a 
wonderful  result  at  a  time  when  there  was  practically  no 
veterinary  knowledge.  For  example  we  select  the  rule 
which  states  that  animals  in  which  the  pleura  is  found  to 
be  adherent  are  unfit  for  food.  Modern  veterinary  know- 
ledge has  shown  that  pleuritic  adhesions  are  an  important 
sign  of  pulmonary  disease  in  animals.  There  are  rules 
about  the  inspection  of  the  spleen  and  intestines.  And 
here  again  many  valuable  signs  of  disease  in  animals  are 
mentioned.  Side  by  side  with  these  important  and  sensible 
laws  there  are  absurd  rules  which  can  only  be  due  to 
caprice  :  for  example  the  law  forbidding  milk  and  meat 
to  be  eaten  together,  and  this  has  been  further  elaborated 
by  certain  rabbis  who  do  not  permit  milk,  butter,  or 
cheese  to  be  eaten  after  meat  until  four  hours  have 
elapsed. 

Modern  science  has  adopted  many  of  these  sensible 
prophylactic  measures.  The  regular  inspection  of  animals 
by  experienced  men  has  added  to  the  list  several  other 
signs  of  disease,  and  on  the  other  hand  has  enabled  us  to 
remove  certain  injurious  conditions.  On  the  whole  the 
endeavour  in  the  Talmud  to  lay  down  the  natural  principles 

18 


THE  HISTORY   OF   THE  PREVENTION  OF  DISEASE 

of   health,   demands   the   greatest  admiration   of   scientific 
men. 

PROPHYLAXIS  AMONG  THE  EGYPTIANS,  ASSYRIANS 
AND  OTHER  ANCIENT  RACES 

We  know  little  about  the  prevention  of  disease  among 
these  races.  They  probably  had  baths  and  anointed  the 
body,  and  observed  certain  rules  about  foods.  It  is  known 
that  the  Egyptians  endeavoured  to  exclude  epidemic  disease 
by  quarantine,  but  the  data  available  are  so  meagre  as 
to  be  of  little  use  for  our  purpose.  The  nations  of  classical 
antiquity,  the  Grreeks  and  Romans,  have  also  done  little  in 
prophylaxis.  These  two  nations  will  be  remembered  for 
their  arrangements  for  the  supply  of  water,  for  drainage 
and  for  baths.  I  will  merely  give  a  few  historical  facts 
which  show  a  partial  and  temporary  attempt  at  prophylaxis. 

It  is  known  that  Lycurgus  ordered  simple  food  for  his 
Spartans,  and  his  rules  are  regarded  as  correct  when  judged 
by  the  physiology  and  chemistry  of  today.  The  Spartan 
broth  is  celebrated.  The  laws  of  Lycurgus  were  intended 
to  train  up  a  strong  warlike  people,  and  the  simplicity  of 
the  food  was  to  accustom  citizens  even  in  times  of  peace  to 
all  kinds  of  hardships,  "Whether  the  custom  of  killing 
weakly  children  soon  after  birth  was  practised  for  any 
length  of  time  is  not  recorded  in  history.  Though  cruel  it 
appears  at  all  events  to  be  an  invaluable  prophylactic.  In 
Athens  we  find  a  well  organized  market  police  supervised 
by  certain  special  officials,  the  ayopavo/xoi.  The  flesh  of 
unborn  lambs  was  excluded  from  the  market  as  being  unfit 
for  food.  Pliny  tells  us  that  a  severe  pestilence  which 
broke  out  among  the  soldiers  of  Alexander  the  Great  on 
the  march  to  India  was  caused  by  eating  bad  fish.  In 
consequence  of  this,  fish  was  prohibited  as  food  for  the 
soldiers. 

In  Rome  from  the  year  388  aediles  supervised  the  cattle 
markets,  shops  and  eating  houses.  They  determined  the 
price  of  meat  and  its  fitness  for  human  consumption.  Goat 
fiesh  was  not  forbidden,  but  was  considered  less  valuable 
than   other  flesh.     We  can  quickly  pass  over  the  classic 

19 


THE  PREVENTION   OF   DISEASE 

races,  because  we  shall  later  have  to  refer  in  another  part 
to  the  services  they  rendered  in  prophylaxis. 


PART  II 

AN  HISTOEICAL  SKETCH  OF  VARIOUS  PEOPHYLACTIC 
MEASURES 

Aftee  the  disruption  of  the  Western  Roman  Empire  the 
political  relations  of  the  civilized  world  were  rearranged 
upon  an  entirely  new  basis.  The  Roman  centralization 
was  lost.  Yet  in  spite  of  the  division  of  the  empire  into 
separate  territories,  some  large,  some  small,  with  different 
languages,  we  find  Roman  civilization  influenced  all  of 
them.  There  is  no  reason  therefore  for  us  to  follow  the 
fate  of  these  countries  and  races  separately,  since  the 
development  was  much  the  same  in  all  these  territories, 
and  they  were  united  by  a  common  culture  and  later  by 
a  common  religion.  "We  shall  therefore  discontinue  the  plan 
hitherto  followed,  and  instead  of  tracing  the  progress  of 
prophylaxis  in  each  separate  nation  we  shall  now  describe 
the  various  prophylactic  measures,  pointing  out  so  far  as 
possible  the  advances  in  prophylaxis  made  by  the  various 
nations.  Repetition  will  be  avoided  wherever  possible, 
though  we  shall  have  to  refer  again  to  pre-Roman  arrange- 
ments to  make  the  subject  complete. 

I.    SUPPLY  OF  WATER 

Not  only  for  prophylactic  reasons  but  also  to  satisfy  an 
urgent  natural  craving,  man  has  always  been  compelled  to 
have  a  supply  of  water.  "When  nature  provided  water 
which  was  disagreeable,  man  was  compelled  to  find  a 
source  of  water  which  was  more  to  his  taste  ;  because,  as 
Pettenkofer  rightly  points  out,  we  drink  water  not  only  as 
a  food  but  also  for  enjoyment.  So  in  "West  Asia  we  find 
numerous  wells  and  cisterns.     In  North  Africa  there  are 

20 


THE   HISTORY   OF   THE   PREVENTION   OF   DISEASE 

wells  three  or  four  metres  wide,  not  far  from  the  Nile, 
which  were  used  for  drinking  and  for  agricultural  purposes, 
and  are  still  worked  today  with  waterwheels.  These  are 
in  the  opinion  of  some  historians  (Eyth)  as  ancient  as  the 
hieroglyphics.  The  Greek  author  Olympiodor  wrote  :  "  The 
oasis  of  Thebes  is  perforated  by  cisterns  like  a  sieve."  A 
number  of  these  water  reservoirs  were  put  in  order  again 
in  the  sixth  decade  of  the  nineteenth  century.  In  China 
too  we  meet  with  many  round  wells  of  very  ancient  date. 
Arrangements  for  supplying  water  were,  as  already  men- 
tioned, made  use  of  by  the  Egyptians  and  the  Romans. 
Some  remains  of  aqueducts  found  in  Egypt  are  of  Roman 
origin,  and  similar  ones  are  found  also  in  Asia  Minor. 

In  the  sixth  century  B.C.  Polycrates  had  built  an  aque- 
duct for  Samos  which  consisted  of  a  tunnel  1,000  metres 
long. 

It  was  the  constant  care  of  the  Roman  emperors  to 
supply  the  Eternal  City  with  sufficient  good  water ;  for 
not  only  was  much  water  required  for  the  numerous  in- 
habitants, but  also  because  the  baths  and  numerous  fish- 
ponds of  various  rich  Romans  had  to  be  supplied  with 
water.  Thus  gradually  magnificent  waterworks  were 
built,  the  oldest  of  which,  the  Appia  Claudia,  was  opened 
in  313  B.C.  A  second  large  aqueduct,  Anio  vetus,  was 
made  in  273  b.c.  ;  and  more  than  a  century  later,  144  B.C. 
a  third  aqueduct,  Aquamarva,  was  completed.  Other 
aqueducts  were  subsequently  built  by  succeeding  emperors. 
Four  of  the  old  aqueducts  are  still  worked  (Aquavergini, 
Aquamarica,  Aqua  felice.  Aqua  Paolo). 

In  the  provinces  too  of  the  old  Roman  empire  there  are 
numerous  aqueducts :  at  Aries,  Avignon,  Arneuil,  Con- 
stantinople, Lyons,  Mayence,  Nimes,  Paris,  and  Treves. 
Several  of  the  provincial  ones  have  in  modern  times  been 
put  in  order  and  are  again  in  use,  as  at  Bologna,  Metz, 
Segovia  and  Spoleto. 

It  is  to  be  regretted  that  the  long  period  which  we  term 
the  middle  ages  allowed  these  splendid  works  to  fall  to 
ruins.  In  recent  years  attempts  have  been  made  in  part 
to  restore  these  and  to  supply  towns  with  water  of  the  best 

21 


THE  PEEVENTION  OF  DISEASE 

quality  in  a  way  formerly  undreamed  of.  What  has  been 
done  in  this  matter  during  the  latter  third  of  the  nine- 
teenth centurj'-  is  so  recent  that  it  is  unnecessary  to  give 
an  account  here. 

II.  BATHS 

As  in  Rome  we  find  waterworks,  so  also  do  we  find  baths. 
It  sounds  almost  incredible  when  we  are  told  that  imperial 
Rome  had  800  public  baths.  It  is  necessary  to  describe 
the  arrangements  in  a  Roman  bath,  and  then  we  shall 
understand  the  very  imposing  ruins  of  these  sanitary  insti- 
tutions (Baths  of  Caracalla). 

Before  bathing  the  Roman  took  a  little  exercise.  The 
room  in  which  he  undressed  was  heated,  and  there  after 
undressing  he  was  anointed  with  oil.  Then  came  the 
application  of  the  strigil,  and  after  this  he  went  into  a 
hot  room  or  a  hot  bath  to  promote  perspiration.  Then 
followed  a  cold  douche  and  a  cold  plunge.  After  these 
elaborate  processes  the  body  was  again  anointed.  These 
baths  formed  to  a  certain  extent  a  centre  for  the  business 
and  social  life  of  the  Romans.  Here  the  events  of  the  day 
were  discussed,  while  some  went  through  gymnastic  exer- 
cises. The  luxury  of  these  baths  seems  not  long  to  have 
survived  the  fall  of  the  Roman  empire.  Not  till  the  time 
of  the  Crusades  do  we  see  a  revival  of  this  institution  in 
Europe.  The  Crusaders,  returning  from  the  East,  tried  to 
reintroduce  the  baths  which  were  so  common  in  the  East. 
Only  in  Spain,  where  the  Moors  ruled  for  a  long  time,  were 
luxurious  baths  established  for  the  sake  of  the  religious 
rites  of  Islam  which  required  believers  to  bathe  frequently. 
The  manner  of  bathing  was  somewhat  different  from  that 
practised  at  Rome.  The  bather,  after  undressing,  wrapped 
round  him  a  woollen  cloak,  put  on  sandals,  and  walked  to 
the  hot  bath.  After  the  bath  he  rubbed  the  hard  parts  of 
the  skin,  the  heel  and  sole  with  pumice  stone,  and  then 
came  anointing  and  sprinkling  with  odorous  essences. 

When  the  Moors  had  been  driven  out  of  Spain  one  of 
the  first  acts  of  the  pious  populace  was  to  raze  to  the 
ground  these  remnants  of  heathendom. 

22 


THE  HISTORY  OF   THE   PREVENTION   OF   DISEASE 

The  baths  which  were  established  in  Germany,  France 
and  England  through  the  initiative  of  the  Knights  of  the 
Cross  soon  met  with  great  approval.  It  became  a  custom 
to  take  a  bath  before  ceremonies  such  as  marriage  or 
knighting.  So  too  on  the  eve  of  a  festival  every  one  went 
to  his  bath.  Then  the  various  reigning  princes  claimed  the 
income  from  baths  ;  they  formed  part  of  the  so-called  royal 
prerogatives.  By  transfer  or  by  lease  these  were  made  over 
to  the  towns,  and  a  special  guild  superintended  and  man- 
aged the  baths.  These  were  regarded  in  the  light  of  cura- 
tive agents,  and  it  is  evident  that  the  founders  of  these 
institutions  attached  to  them  an  hygienic  value.  It  is 
worthy  of  note  that  every  Saturday  the  artisans  were  called 
to  their  bath  by  a  trained  band  of  youths  who  carried 
drums.  Vapour  baths  were  introduced  in  the  twelfth 
century. 

Besides  the  public  baths  every  rich  citizen  had  a  bath- 
room fitted  up  in  his  own  house,  a  room  which  served  also 
for  entertaining  his  friends.  Here  the  friends  of  the  house 
assembled  for  feasts  and  banquets,  but  each  guest  first  took 
a  bath. 

But  in  addition  to  these  admirable  baths  the  Knights  of  the 
Cross  brought  something  less  welcome  with  them  from  the 
East,  namely  leprosy,  and  many  baths  were  doubtlessly  estab- 
lished because  of  this  terrible  disease.  At  least  it  has  been 
shown  that  so-called  "  soul-baths  "  were  founded  especially 
for  the  poor  by  benevolent  persons  both  to  prevent  and  to 
cure  leprosy.  It  was  a  well  meant  but  dangerous  kind  of 
benevolence,  for  it  soon  became  evident  that  this  method 
of  trying  to  prevent  leprosy  was  the  very  way  in  which 
to  spread  it.  And  so  it  could  not  but  happen  that  many 
physicians  became  determined  opponents  of  baths.  Another 
circumstance  too  tended  to  discredit  these  baths.  In  the 
middle  ages,  that  remarkable  period  which  is  characterized 
by  religious  fanaticism  and  indulgence  in  excesses,  these 
baths  were  often  used  for  the  wildest  orgies  and  shameless 
licentiousness.  The  clergy,  physicians  and  statesmen  then 
opposed  these  public  bathing  institutions  and  the  good  was 
thrown  away  with  the  bad,  for  owing  to  this  opposition  on 

23 


THE  PREVENTION   OF   DISEASE 

all  sides  and  to  the  danger  to  health  caused  by  these  badly 
managed  baths,  most  towns  gave  up  their  public  baths. 

It  should  be  mentioned  that  at  the  commencement  of 
the  seventeenth  century  a  number  of  cases  of  syphilis 
which  occurred  in  Brlinn  were  traced  without  any  doubt  to 
an  infection  at  a  bath.  To  understand  this  we  must  re- 
member that  it  was  the  custom  in  many  places  to  cup  the 
bather  directly  after  the  bath,  and  the  cupping  instrument 
was  not  always  carefully  cleaned  after  each  time  of  being 
used. 

Instead  of  these  public  baths,  which  were  being  closed 
nearly  everywhere  in  Germany,  the  custom  arose  of  going 
to  some  bathing  resort.  Places  which  were  pleasantly  situ- 
ated and  especially  which  had  water  with  curative  proper- 
ties were  frequented  in  the  summer  by  rich  people.  One  of 
the  oldest  of  these  bathing  resorts  is  Baden  in  Aargau,  if  we 
omit  Aix-la-Chapelle  which  was  much  frequented  even  in 
the  time  of  Charlemagne. 

Vapour  baths  were  introduced  into  France  rather  earlier 
than  into  Germany.  They  were  called  "  etuves."  As  in 
Germany,  a  guild  of  bathers  was  established,  called  the 
"  etuveurs."  Cold  baths  and  sea  baths  were  first  known  in 
England,  and  this  English  custom  was  brought  to  Germany 
in  the  eighteenth  century  by  physicians  who  had  been  to 
England  (Hufeland  and  Halm).  The  cold  water  institutions 
on  the  continent  date  from  the  nineteenth  century. 

The  value  of  the  bath  as  a  prophylactic  and  curative  agent 
is  thoroughly  accepted.  The  perspiring  which  is  produced 
by  vapour  baths  has  certainly  helped  to  get  rid  of  the 
toxins  of  certain  diseases,  and  the  use  of  cold  water  after  a 
hot  bath  or  to  rub  down  the  body  fortifies  the  body  and  is 
valuable  in  enabling  it  to  resist  atmospheric  influences  as 
has  been  fully  recognized  in  all  ages. 

III.— THE  EEMOVAL  OF  EEFUSE  AND    THE    DISPOSAL 
OF  THE  DEAD 

Old  historical  records  and  ruins  of  buildings  connected 
with  the  removal  of  refuse  from  towns  are  much  more 
scanty   than   those   connected   with   the   supply  of  water. 

24 


THE  HISTORY   OF   THE  PREVENTION   OF  DISEASE 

Probably  this  refuse  which,  would  be  injurious  to  health 
was  removed  in  the  simplest  way  and  used  to  manure  the 
land.  But  there  appears  certainly  to  have  been  the  opinion 
that  removal  of  the  refuse  by  drains  was  only  practicable 
with  a  simultaneous  flushing. 

The  following  are  some  of  the  facts  as  to  drainage  which 
have  come  down  to  us.  Babylon,  Carthage  and  Egypt 
are  said  to  have  had  systems  of  drainage,  and  Jerusalem 
in  the  Herod ian  period  is  reputed  to  have  such  a  system 
to  carry  away  the  waste  water  into  special  reservoirs. 
Here  the  impurities  were  allowed  to  settle  to  the  bottom 
as  in  settling  tanks,  the  water  in  the  reservoir  was 
then  allowed  to  run  off  and  the  sediment  was  used  as 
manure. 

Up  to  the  present  day,  as  mentioned  above,  the  Cloaca 
Maxima  in  Rome  laid  out  by  Tarquinius  Prisons  is  still  in 
use.  It  was  built  not  so  much  for  the  purpose  of  removing 
refuse  but  to  drain  the  town  and  marshy  places.  Later,  all 
polluted  water  was  also  drained  into  it.  It  emptied  itself  into 
the  Tiber  below  Rome.  But  even  in  Augustus'  time  it  was 
noticed  that  the  fluctuating  stream  caused  a  backward 
flow  of  the  debris  which  led  to  serious  results.  The 
emperor  in  consequence  of  this  ordered  that  the  drains 
should  be  regularly  flushed. 

During  the  middle  ages  very  little  was  done  to  keep  the 
towns  systematically  clean.  The  oldest  structure  which 
exists  in  Germany  for  drainage  of  a  town  is  that  of  the  old 
pottery  town  of  Bunzlau  which  was  regularly  flushed  by 
means  of  a  system  of  drainpipes  as  early  as  1559.  A 
similar  arrangement  was  started  in  Prague  in  the  seven- 
teenth century.  The  oldest  drains  in  modern  Europe  are  in 
England.  Almost  every  large  town  was  provided  with  a 
system  of  drains,  regularly  flushed,  and  many  date  back 
to  the  sixteenth  century.  But  even  in  England  the 
polluted  water  was  conveyed  into  the  nearest  stream.  It  is 
only  since  1859  that  attempts  have  been  made  to  do  away 
with  this  evil.  London  took  the  lead.  By  means  of  an 
intercepting  sewer  the  sewage  was  conveyed  to  an  outfall 
below  London  where  it  was  allowed  to  escape  only  on  the 

25 


THE  PREVENTION   OF  DISEASE 

ebbing  tide  into  the  Thames.  But  when  this  measure  was 
also  found  inadequate,  the  sewage  was  previously  submitted 
to  a  process  of  precipitation  with  the  view  of  purifying  the 
eiEuent. 

Hamburg,  following  England's  example,  commenced  to 
build  drains  in  the  fifties  of  the  nineteenth  century.  Dant- 
zig  was  the  first  town  in  Germany  to  have  at  the  same 
time  a  drainage  system,  a  water  supply  system  and  irriga- 
tion. Berlin,  too,  since  1875  has  built  a  similar  system 
which  ranks  amongst  the  greatest  installations  for  drainage 
of  the  century.  Almost  all  large  communities  nowadays 
have  followed  the  excellent  example  of  these  towns. 

The  methods  employed  for  the  disposal  of  the  dead  do  not 
show  any  very  clear  idea  of  prophylaxis.  In  Grreece  and 
heathen  Rome  the  dead  were  burnt.  The  Israelites  buried 
the  dead  in  the  earth  at  a  depth  prescribed  by  their  laws. 
The  European  nations  which  sprang  up  out  of  the  former 
Roman  empire  seem  not  to  have  had  any  strict  regulations 
about  burial  till  very  much  later.  Not  even  coffins  were  in 
general  use,  and  there  were  no  regulations  as  to  the  depth 
of  graves. 

The  churchyard  was  to  only  the  slightest  extent  the 
property  of  the  community,  but  rather  belonged  to  the 
church  authorities,  and  was  always  chosen  so  as  to  be  near 
the  church.  Hence  the  name  churchyard,  which  is  still 
at  the  present  day  used  to  designate  the  place  of  burial. 
In  South  Grermany,  especially  in  Bavaria,  the  word  Friedhof 
(cemetery)  is  general.  But  the  expression  Friedhof  (place  of 
peace)  does  not  mean  that  those  who  rest  there  have  found 
peace,  but  that  the  spot  is  separated  and  fenced  around. 

IV.  EULES  CONCERNING  MEAT. 
All  historical  records  about  this  subject  show  that  all 
settled  peoples  who  did  not  themselves  rear  animals  for 
food  supplies,  but  were  obliged  to  buy  meat  from  markets, 
were  protected  by  certain  laws  against  fraud  and  against 
articles  of  inferior  value.  These  laws  have  already  been 
referred  to  so  far  as  they  concern  the  ancient  races. 

We  shall  now  consider  the  regulations  which  were  pro- 

26 


THE  HISTORY  OF  THE  PREVENTION   OF   DISEASE 

mulgated  after  the  decline  of  the  Western  Roman  Empire. 
These  laws  are  mostly  of  municipal  origin.  Every  com- 
munity had  its  own  police  regulations  about  food.  The 
government  and  the  ecclesiastical  authorities  rarely  inter- 
fered in  the  matter. 

It  requires  mention  that  the  German  apostle  Winfried 
Bonif acius  forbade  the  use  of  horseflesh  which  was  so  much 
eaten  in  Germany,  because  he  attributed  to  its  use  impurity 
of  the  blood  and  leprosy.  But  if  we  examine  a  little  more 
closely  into  the  reason  of  it  we  shall  probably  come  to  the 
conclusion  that  it  was  dictated  by  a  religious  rather  than 
a  sanitary  motive,  for  it  is  well  known  that  horseflesh  was 
eaten  by  the  old  Germanians  at  their  religious  festivals  at 
the  solstice,  so  that  the  order  struck  at  heathen  ceremonies 
in  which  the  horse  was  a  symbol.  This  may  also  have 
been  the  reason  why  the  eating  of  horseflesh  was  forbidden 
by  the  Council  of  Celeia  in  787.  On  the  other  hand  Pope 
Zacharias  seems  to  have  forbidden  the  eating  of  pork  and 
of  bacon  from  purely  sanitary  motives.  In  the  time  of 
Charlemagne  the  question  was  often  discussed  whether  the 
flesh  or  blood  of  an  animal  which  had  died  or  had  been 
killed  by  other  animals  might  be  eaten. 

Towards  the  end  of  the  eleventh  and  commencement  of 
the  twelfth  century  a  guild  of  butchers  was  established  in 
most  towns  of  Germany.  In  free  cities  these  were  super- 
vised by  masters  of  the  guild  specially  chosen  for  the  work ; 
in  other  towns  sometimes  by  overseers,  burgraves  and  other 
imperial  offlcials.  The  oldest  known  charter  which  contains 
regulations  about  meat  is  probably  that  of  the  town 
Freiburg  in  Breisgau  in  the  year  1120.  These  data  have 
been  taken  from  the  very  thorough  treatise  written  by 
Ernst  Graber,  to  which  all  interested  in  the  subject  are 
referred.  We  reproduce  here  only  a  few  selections  from 
this  book. 

It  is  interesting  to  learn  from  an  old  deed  of  the  town  of 
Augsburg  of  the  year  1276,  that  slaughtering  was  forbidden 
except  in  slaughter  houses.  Slaughter  houses  must  have 
already  been  in  existence  therefore  at  this  period.  In  many 
documents    warnings   are  given   against   measly  flesh,  in 

27 


THE  PREVENTION  OF  DISEASE 

others  against  leprous  flesh,  mangy  sheep  and  the  flesh  of 
calves  which  were  too  young.  In  many  documents  is  a  law 
ordering  that  inferior  meat  must  be  sold  separately  from 
good  meat. 

The  conditions  under  the  Holy  Roman  Empire  were  most 
unfavourable  for  the  carrying  out  of  sanitary  measures. 
There  is  hardly  any  sign  of  any  central  initiative  authority ; 
not  only  did  every  sovereign  make  laws  for  his  small 
territory,  but  every  community  in  it  had  its  own  special 
laws.  Only  towards  the  end  of  the  fifteenth  century  do  we 
find  an  endeavour  to  supplant  these  separate  powers  by  a 
strong  central  authority.  Charles  V,  whose  misfortune  it 
was  that  he  did  not  understand  the  age,  and  regarded  the 
mightiest  movements  in  human  history  as  a  mere  revolt 
by  unruly  men  and  discontented  priests,  nevertheless 
endeavoured  to  strengthen  the  imperial  power  and  to 
extend  it.  He  was  helped  on  the  one  hand  by  the  natural 
decay  of  the  feudal  system,  on  the  other  hand  by  the  new 
development  of  science  which  began  to  stir  again  during 
his  reign  after  a  pause  of  several  centuries.  The  voices  of 
physicians  too  began  to  be  heard.  And  thus  during  the 
reign  of  this  emperor  an  imperial  sanitary  police  was 
established  in  the  year  1530.  They  adopted  special  mea- 
sures for  beer,  wine,  bread  and  meat,  and  fixed  the  price  of 
these.  At  the  famous  Imperial  Diet  held  at  Augsburg  in 
the  year  1648  these  laws  were  brought  again  to  the  notice 
of  all  authorities  with  penal  regulations. 

Under  this  emperor  experts  upon  hygienic  and  prophy- 
lactic questions  were  for  the  first  time  in  Grermany  drawn 
from  the  ranks  of  the  physicians.  At  that  time  too  a  few 
scientific  works  dealing  with  the  preservation  of  health 
were  written,  as  Von  Striippen's  Nutzliche  Reformation  zu 
guter  Gesundheit  und  Christliche  Ordnung  and  a  German 
edition  of  Fortunus  Fidelis  (Nissus  sive  medicinae  patro- 
cmium,  Panorma,  1698).  In  1559  official  inspection  of 
slaughtered  animals  in  Vienna  was  ordered  by  the  State. 
In  1582  an  order  was  issued  by  the  government  of  the 
palatinate  that  all  meat  exposed  for  sale  in  the  butchers' 
shops  must  be  labelled.     Measly  meat  was  to  be  sold  at  a 


THE  HISTOKY   OF  THE   PREVENTION   OF   DISEASE 

special  place,  and  flesh  which  was  very  measly  was  not  to 
be  sold  at  all. 

The  disgusting  custom  of  blowing  up  meat  was  practised 
in  earlier  times  even  more  than  at  the  present  day.  Lich- 
tenberg  issued  a  rescript  in  1587  which  described  this 
process  as  disgusting,  deceptive  and  dangerous  to  health 
("  because  many  butchers  have  an  unwholesome  and  dis- 
agreeable breath  "). 

During  that  sanguinary  time  when  a  tedious  war  damaged 
the  prosperity  of  Grermany  for  centuries,  it  is  scarcely 
possible  to  speak  of  an  imperial  authority.  The  power  of 
the  various  princes  which  Charles  V  attempted  in  vain  to 
suppress  was  a  sovereign  power  equal  to  that  of  the 
emperor  himself.  The  most  powerful  prince  of  that  age, 
the  Elector  Friedrich  Wilhelm  of  Prussia,  in  those  stormy 
days  raised  the  condition  of  his  country  with  marvellous 
energy  in  spite  of  the  dangers  of  war  and  its  distresses. 
Prussia  already  possessed  sanitary  regulations,  and  these 
were  consolidated  by  the  edict  of  1685,  while  for  the 
regulation  of  medicine  a  central  institution  was  established 
for  Prussia,  the  "Collegium  Medicum"  consisting  of  physi- 
cians. After  that  uniform  market  regulations  were  drawn 
up  for  the  whole  country.  In  the  year  1769  a  second 
college  was  established,  the  "Collegium  Sanitatis."  The 
object  of  founding  this  second  college  was  "  under  the 
Divine  grace  and  care  to  protect  our  province  and  lands 
from  the  pestilential  plague  and  other  contagious  diseases 
and  to  prevent  the  cattle  from  dying,  so  far  as  this  is  pos- 
sible." Meantime  a  provincial  medical  college  had  been 
established  in  every  province,  and  in  1786  the  "  Collegium 
Sanitatis "  was  instructed  to  combine  with  these  and  to 
take  over  "  the  supervision  of  all  institutions  against 
epidemic  disease,  pestilence  among  cattle  and  -of  all  that 
concerns  the  maintenance  of  health  and  the  removal  of 
causes  of  disease  among  men  and  cattle."  In  1799  these 
two  colleges,  "  Collegium  Sanitatis  "  and  "  Medicum,"  were 
united  and  were  provided  with  more  extensive  duties. 
They  were  to  occupy  themselves  with  and  examine  into 
everything  which  might  be  injurious  to  health,  to  look  out 

29 


THE  PEEVENTION  OF  DISEASE 

for  any  abuses  and  to  remove  them  by  suitable  sanitary 
rules  and  precautions  ;  they  were  also  to  see  that  the  food 
was  wholesome. 

In  other  countries  too  similar  rules  were  made  about  this 
time :  for  example  in  1712  in  Hanover.  In  1716  it  was 
ordered  in  Hanover  that  all  cattle  should  be  examined 
while  still  alive.  If  considered  healthy  a  mark  was 
branded  upon  the  horn  of  the  animal.  It  was  kept  three 
days,  then  again  examined,  and  allowed  to  be  slaughtered 
if  this  second  inspection  showed  the  animal  to  be  healthy. 
A  few  unconscientious  dealers  imported  smoked  and  salted 
meat  from  abroad  which  came  from  diseased  animals,  and 
a  law  was  consequently  passed  forbidding  the  importation 
of  smoked  and  salted  meat.  In  1732  an  order  was  issued  in 
Hanover  that  calves  which  had  been  suckled  by  diseased 
kine  should  not  be  slaughtered  till  they  had  been  taken 
away  from  the  diseased  mother  and  had  been  fed  upon 
healthy  milk  for  at  least  eight  days.  In  the  meantime 
they  were  to  be  carefully  examined,  and  especially  the 
tongue  was  to  be  examined  for  any  ulcers.  If  not  healthy 
such  calves  were  to  be  slaughtered  by  an  ofhcial,  but  not  in 
the  slaughter  house,  and  were  to  be  buried  with  their  skin 
and  hair  at  a  depth  of  four  ells. 

Since  1803  regulations  have  existed  in  Prussia  to  prevent 
pestilence  among  cattle.  But  the  greatest  reform  in  this 
matter  was  the  establishment  of  veterinary  schools,  the  first 
of  which  was  instituted  in  1824  at  Stuttgart.  Unfortu- 
nately these  measures  to  ensure  the  meat  being  sound  were 
not  carried  out  continuously.  It  is  especially  noticeable 
that  the  regulations  about  slaughter  houses  were  gradually 
disregarded,  so  that  in  1842  there  was  no  longer  any  public 
slaughter  house  in  Berlin,  although  a  short  time  previously 
there  had  been  three.  It  is  remarkable  that  this  condition 
of  things  was  possible  under  the  strict  Prussian  rule.  Then 
Kiichenmeister's  epoch-making  discovery  about  intestinal 
worms  exposed  the  danger  to  the  public  of  meat  derived 
from  private  slaughter  houses  which  were  not  under  super- 
vision. A  still  more  lasting  impression  was  produced  by 
the   great    epidemics   of   trichiniasis   which  broke  out  in 

30 


THE  HISTORY  OF  THE  PREVENTION  OF  DISEASE 

Germany  in  1864.  As  a  result  of  this  the  Medical  Society 
in  Berlin  appointed  a  committee  to  inquire  into  the  sub- 
ject of  trichiniasis  and  the  prevention  of  this  dangerous 
disease,  and  the  outcome  of  this  inquiry  was  a  unanimous 
recommendation  by  this  learned  society  that  supervised 
slaughter  houses  should  be  established  in  at  any  rate  all 
the  larger  towns  of  the  kingdom.  The  recommendation 
was  not  made  in  vain.  And  soon  there  was  no  large  com- 
munity in  Germany  which  did  not  possess  its  slaughter 
house,  or  at  least  was  preparing  to  have  one. 

The  crown  to  this  sanitary  work  is  the  establishment  in 
our  own  day  of  the  Imperial  Board  of  Health.  Still  it 
should  be  mentioned  that  even  before  this  imperial  institute 
was  founded  various  districts  of  Germany,  such  as  Bavaria, 
Saxony  and  Wiirtemburg,  had  excellent  regulations  of  their 
own  about  slaughtering  and  market  police. 

V.  RULES  FOR  PERSONAL  PROPHYLAXIS 

In  addition  to  these  police  regulations,  to  which  the  pre- 
vious section  has  been  devoted,  there  were  also  personal 
prophylactic  measures  which  can  be  traced  back  some  of 
them  to  old  prejudices  and  customs,  while  others  rested 
upon  an  apparently  scientific  basis,  and  others  again  upon 
the  custom  of  taking  certain  foods  and  drugs  which  were 
renowned,  sometimes  rightly  and  sometimes  wrongly,  for 
their  efficacy  against  disease. 

1.  Far  into  the  period  of  the  middle  ages  the  mistletoe 
bough  was  regarded  in  Germany  and  in  England  as  a 
preventive  of  disease  and  evil  spirits.  The  custom  arose 
out  of  German  myths.  Another  plant  which  was  used  to 
protect  against  disease  is  the  mandrake  root.  It  is  how- 
ever difficult  to  conceive  how  the  foolish  belief  in  this  root 
originated.  Some  authors  maintained  that  it  possessed  a 
slight  resemblance  to  the  distorted  face  of  one  who  had 
been  hanged.  It  is  certain  that  even  in  the  sixteenth 
century  the  mandrake  root  was  considered  a  most  valuable 
remedy  by  the  apothecaries  of  that  day ;  that  it  was  kept 
in  special  boxes  called  coffins,  and  only  sold  for  very  large 
sums.     According  to  Kiihn  the  custom  is  said  to  be  con- 

31 


THE  PEEVENTION   OF  DISEASE 

nected  with  fire  worsliip  in  India  and  in  Germany,  and  it 
is  often  put  for  the  ash  (the  tree  of  Odin),  the  mistletoe, 
the  hazel  (magic  wand)  and  the  mullein.  But  if  the 
Hebrew  word  "dadaim"  is  correctly  translated  by  "man- 
drake root,"  it  was  already  in  the  Bible  regarded  as  a 
means  against  sterility  in  women.  It  is  mentioned  as  pos- 
sessing this  power  in  Grenesis  chap.  xxx.  verse  14.  This 
would  show  that  it  was  regarded  as  a  prophylactic  also  by 
races  which  were  not  of  Indo-European  origin, 

Pliny,  in  his  Natural  History^  also  records  that  the  man- 
dragora  is  valued  as  possessing  many  kinds  of  prophylactic 
and  curative  properties.  Calomella  translates  the  Greek 
name  by  semihominis,  and  perhaps  to  this  name  is  owing 
the  tradition  that  the  plant  grows  only  below  the  gallows 
of  a  man  who  has  been  hanged  although  he  was  innocent. 
Charlatans  tell  all  sorts  of  marvellous  stories  about  the 
danger  incurred  in  getting  the  plant,  and  ask  a  correspond- 
ingly high  price  for  it.  Sixty  thalers  gold  and  even  more 
have  been  paid  for  one  mandrake.  "  They  may  only  be 
gathered  at  full  moon,  and  the  plant  is  only  efficacious 
when  pulled  up  with  its  root.  At  the  moment  when  it  is 
thus  pulled  up,  the  plant  utters  such  a  terrible  cry  that  he 
who  hears  the  cry  dies  of  fright.  Therefore  it  has  to  be 
tied  to  the  tail  of  a  large  strong  black  dog,  and  the  dog  is 
enticed  by  a  piece  of  meat  placed  some  little  distance  away. 
As  the  dog  snaps  at  the  meat  the  plant  is  torn  out  with 
its  root,  and  the  dog  of  course  pays  the  penalty  of  losing 
his  life." 

A  doll  was  carved  out  of  the  root  in  the  form  of  a  human 
being,  was  dressed  in  grand  clothes,  concealed  in  a  valuable 
box  called  a  "  coffin  "  in  some  secret  corner  of  the  house ; 
it  was  washed  every  month  with  wine  and  water  and 
dressed  in  new  garments.  The  possession  of  such  a  man- 
drake root  protected  against  all  kinds  of  dangers,  removed 
sterility,  made  childbirth  easier,  lessened  the  labour  pains, 
and  guaranteed  a  good  lying-in  period.  However  in 
ancient  times  other  plants  were  used  for  the  same  pur- 
pose, as  aglaophotis  and  the  peony. 

Mistletoe  is  even  up  to  the  present  time  regarded  as  a 

32 


THE  HISTORY   OF    THE   PEEYENTIOX   OF   DISEASE 

valuable  prophylactic.  Its  fame  rests  upon  the  G-erman 
myth  of  Baldur's  death.  Among  the  ancient  Grermans,  a 
priest  in  a  white  garment  had  to  cut  it  from  the  tree  with 
a  gold  sickle  and  catch  it  in  a  white  vessel.  In  Sweden  it 
is  still  today  regarded  as  a  tree  which  protects  against 
disease  (especially  epilepsy)  and  against  burning.  In  Eng- 
land it  is  the  tree  of  love.  A  drink  prepared  from  it 
removes  sterility,  protects  against  every  poison,  and  heals 
every  disease.  Epileptics  should  always  carry  a  piece  of 
mistletoe  with  them,  because  it  prevents  epileptic  attacks. 
In  Germany  huntsmen  prize  it  because  it  brings  luck  in 
hunting,  and  because  any  injury  sustained  while  hunting 
will  quickly  heal. 

The  juice  of  the  ash  protects  against  the  bites  of  venomous 
snakes.  In  Scotland  the  sap  of  the  mountain  ash  is  given 
to  newborn  infants  instead  of  honey  to  protect  them  from 
cramp  and  diseases  of  the  eye — "  Infante  nato  obstetrix 
Scotiae  montaneae  viridis  fraxini  ramusculum  igni  immittit, 
succum  inde  imanentem  ista  deinde  ori  infundit  infantis, 
ut  primum  ejus  nutrimentum"  (Finn  Magnussen").  In 
Grermany  chaplets  of  mistletoe  and  coral  were  valued  as 
protective. 

Lastly  we  must  mention  aU  those  things  which  are 
renowned  as  prophylactics.  Some  of  these  are  connected 
with  the  Christian  religion,  others  are  inherited,  and  others 
again  are  found  by  accident. 

Baptismal  water  protects  against  cramp  and  inflamma- 
tion of  the  eyes  of  children  (East  Friesland  and  Thiiringen). 
Consecrated  water,  especially  when  hailstones  have  chanced 
to  fall  into  it,  protects  men  and  animals  against  disease  of 
all  forms  (Thiiringen).  A  consecrated  wafer  will  protect 
man  and  animal  from  cramps  ;  so  too  will  sacramental  wine 
(Lauenburg).  Whoever  drinks  this  wine  on  the  day  of 
consecration  will  be  protected  the  whole  year  against  poison, 
witchcraft  and  lightning  (Bavaria).  Wax  candles  which 
are  consecrated  on  Candlemas  Day  are  fastened  around  the 
wrist  of  women  in  labour.  This  will  give  an  easy  delivery 
and  a  good  lying-in  period.  The  candle  is  most  efficacious 
when  Candlemas  faUs  upon  a  Sunday. 

33  D 


THE  PREVENTION  OF  DISEASE 

A  little  metal  scraped  off  a  church,  bell  and  taken,  is 
specially  valuable  in  protecting  cattle  from  all  forms  of 
illness,  and  it  is  also  useful  for  man.  The  bellrope  has  a 
similar  effect ;  and  so  too  the  fat  with  which  the  axle  of 
the  bell  is  greased.  The  buds  on  plants  consecrated  on  Palm 
Sunday  protect  against  swelling  in  the  throat  and  fevers, 
especially  in  children.  Candles,  cloths,  ribbons,  aprons  and 
pots  which  have  been  used  for  church  ceremonies,  have  a 
great  reputation  as  prophylactics.  So  too  consecrated  nose- 
gays of  nine  different  kinds  of  flowers ;  also  the  wedding 
ring,  bridal  dress  and  bridal  wreath. 

Among  things  inherited  old  Bibles  rank  high  as  pro- 
tectives  (especially  the  Apocalypse).  ItaHans  carried  on  a 
large  trade  in  these  at  the  commencement  of  last  century. 
These  were  often  placed  in  the  infant's  cradle  to  protect  it 
from  cramp.     Old  hymnbooks  served  the  same  purpose. 

Among  articles  found  the  horse's  hoof  is  famous  even  at 
the  present  day.  Its  prophylactic  value  is  great  against 
all  infectious  disease. 

In  all  these  things  there  was  always  some  religious  idea 
or  some  feeling  of  compassion ;  but  another  custom,  which 
we  can  trace  back  into  the  distant  past,  was  more  brutal, 
and  had  to  be  performed  by  the  blood  of  one  who  had  been 
executed,  though  innocent.  Indeed  prophylactic  value  was 
ascribed  to  everything  connected  with  an  execution  or 
murder  or  death. 

As  late  as  the  year  1861  the  foolish  populace  of  Hanau 
rushed  on  to  the  scaffold  on  which  a  thidf  was  executed 
for  murder,  in  order  to  get  a  few  drops  of  the  blood  while 
still  warm ;  and  in  1864  at  Berlin  the  executioner  after 
executing  two  thieves  who  had  committed  murder,  dipped 
a  quantity  of  linen  into  the  blood  which  flowed  out  and 
quickly  sold  the  linen  for  two  thalers  a  piece.  This  blood 
protects  against  epilepsy  and  cures  it.  The  nail  to  which 
was  fastened  the  rope  by  which  a  man  was  put  to  death 
was  made  into  gout-rings — that  is,  rings  which  protect 
against  gout.  The  gladiators  at  E-ome  used  to  drink  the 
blood  of  those  who  had  been  hanged,  and  so  protected  them- 
selves from  epilepsy ;  and  bread  which  contained  some  of 

34 


THE   HISTORY   OF   THE   PREVENTION   OE   DISEASE 

this  blood  protected  against  gout.  The  bones  and  the  cord 
with  which  the  victim  was  hanged  answered  the  same 
purpose. 

In  France  at  the  present  day  the  fat  of  criminals  is 
asked  for  at  druggists',  as  a  protection  against  consumption. 
In  the  fifties  a  murderer  in  Switzerland  confessed  that  he 
had  slain  an  innocent  victim,  that  he  might  have  the  blood 
and  so  protect  himself  against  madness.  "Whether  now  and 
again  some  of  the  many  inexplicable  murders  the  motive 
for  which  is  so  difficult  to  discover  (such  as  "  Jack  the 
Ripper")  may  not  be  connected  with  this  superstitious 
belief  is  at  least  worthy  of  discussion.  The  old  unfortunate 
superstition  still  exists  among  prostitutes,  that  they  can  be 
protected  against  the  contagious  diseases  to  which  their 
dishonourable  trade  exposes  them  if  they  first  have  inter- 
course with  an  innocent  youth. 

2.  Among  methods  which  have  come  down  to  us  from 
earliest  antiquity,  and  to  which  still  today  great  prophy- 
lactic value  is  ascribed,  are  blood  letting,  cures  by  purgation 
and  cures  by  sweating.  The  three  were  very  frequently 
combined. 

In  the  foregoing  pages  it  has  been  possible  to  separate 
the  prophylactic  measures  from  therapeutic  ones,  but 
this  is  not  possible  for  the  above  mentioned  practices. 
Probably  the  idea  of  these  cures  first  suggested  itself  to 
the  mind  at  the  bedside ;  they  were  then  used  for  patients, 
and  later  came  to  be  used  as  preventives  of  the  diseases  in 
which  they  had  proved  efficacious.  Venesection  was  prob- 
ably the  most  unfortunate  of  these. 

Pliny,  in  his  Natural  History^  calls  the  hippopotamus  the 
introducer  of  blood  letting,  and  relates  that  when  this 
animal  feels  plethoric  it  goes  to  the  stubble  in  the  field  and 
opens  a  vessel  of  the  thigh  with  the  sharp  points  of  the 
stubble.  It  then  closes  the  wound  with  mud.  This  absurd 
story  of  Pliny's  rests  upon  a  correct  observation  that  the 
sweat  given  ofi*  by  the  hippopotamus  is  bloodstained. 
Stephanus  Byzantius,  a  writer  of  the  fifth  century,  says 
that  venesection  was  introduced  by  Pataleios,  a  son  of 
Aesculapius.     He  is  said    to  have   been   stranded   upon   a 

35 


THE   PREVENTION   OE  DISEA8E 

distant  island  wlien  a  yontli,  and  to  have  opened  a  blood 
vessel  and  so  saved  tlie  life  of  a  maiden  who  had  become 
unconscious  after  a  fall.  The  maiden,  daughter  of  a  shep- 
herd on  the  island,  was  afterwards  married  by  the  successful 
physician.  The  ojieration  later  was  much  practised  by  the 
followers  of  Aesculapius  in  their  temples. 

In  the  Coan  Prognostics  it  is  taught  that  venesection 
should  be  performed  for  threatened  haemorrhage  in  impor- 
tant organs.  Hippocrates  recommends  venesection  for 
febrile  diseases,  for  pain  in  the  breast  when  commencing, 
for  difficult  micturition,  threatening  apoplexy  and  loss  of 
speech.  This  shows  that  he  employed  venesection  not 
only  in  illness  but  also  when  a  patient  seemed  likely  to 
become  ill. 

Ohrisippus  of  Cnidus,  a  Pythagorean,  condemns  venesec- 
tion for  mystic  religious  reasons  (Gralen,  de  Venaesectione)^ 
because  the  Pythagoreans,  like  the  Israelites  and  several 
other  ancient  races,  believed  that  the  soul  was  located  in 
the  blood  and  venesection  would  lead  to  a  reduction  of  the 
soul's  function.  His  renowned  pupil,  Erasistratus,  one  of 
the  founders  of  the  Alexandrian  school,  is  also  no  friend  of 
venesection.  As  a  substitute  for  it  another  Alexandrian 
Appollonius  recommended  cupping.  The  Empirics  allowed 
a  wider  field  for  venesection.  Yet  a  contemporary  of 
Trajan,  Menodatus  of  Nicomedia,  would  limit  it  to  cases 
in  which  important  organs  are  threatened  with  congestion. 
Asclepiades,  who  introduced  Greek  medicine  into  Rome 
and  was  also  an  empiric,  recommends  venesection  for 
threatening  apoplexy,  but  gives  the  warning  that  in 
other  cases  its  use  should  depend  upon  the  climate.  In 
temperate  climates  it  should  be  performed  less  often  than 
in  hot  climates. 

The  Methodists  ascribed  to  blood  letting  a  depletive 
effect,  and  recommended  it  for  plethoric  constitutions. 
Galen,  Oribasius  and  Aetius  recommended  venesection  at 
the  commencement  of  every  inflammation. 

Trains  was  a  great  friend  of  venesection  and,  contrary 
to  the  opinion  of  his  predecessors,  he  thought  it  did  not 
matter  which  vein  was  opened.     At  that  time  the  schools 

36 


THE   HISTORY   OF   THE   PREVENTION   OF   DISEASE 

taugM  that  sometimes  the  vessel  to  be  opened  should  be 
near  the  diseased  organ,  sometimes  that  it  should  be  on  the 
side  opposite  to  that  upon  which  the  disease  was. 

The  Arabians,  especially  Ehazes,  were  upon  the  whole  in 
favour  of  venesection,  but  they  too  thought  that  climate 
should  modify  its  use.  Avicenna,  the  most  famous  Arabian 
physician,  was  much  more  careful  than  Rhazes  in  his 
enumeration  of  indications  for  venesection.  He  considered 
climate  and  season  as  valuable  factors  in  deciding  upon  the 
operation,  and  he  also  took  into  consideration  astrological 
data.  In  the  sixteenth  century,  Brissot  thought  that 
venesection  should  be  specially  recommended  as  a  preven- 
tive against  epidemic  diseases. 

Batelli  was  an  enthusiastic  advocate  of  venesection  (De 
Sanguinis  Missione,  Leyden,  1660).  It  should  be  done  for 
plethora  and  when  the  blood  was  corrupt.  Neither  age,  sex, 
nor  constitution  was  a  contra-indication  to  blood  letting  ; 
but  one  ought  not  to  withdraw  too  little  blood.  Two  to 
three  pounds  should  be  withdrawn  at  one  time,  or  at  least 
a  sufficient  quantity  to  produce  fainting.  This  was  done 
both  to  protect  against  disease  and  to  cure  disease,  and  he 
held  that  it  was  false  to  assume  that  blood  letting  dimin- 
ished the  quantity  of  blood.  Just  as  the  quantity  of  milk 
in  the  breast  is  increased  by  suckling,  so  the  removal  of 
blood  by  venesection  leads  to  the  formation  of  fresh  blood. 
The  blood  which  was  withdrawn  was  laden  with  waste 
matters,  and  was  replaced  by  good  pure  healthy  blood. 
The  medical  faculty  of  Paris  opposed  this  cruel  absurdity, 
but  in  spite  of  this  protest  and  in  spite  of  the  rule  which 
was  made  by  this  faculty  forbidding  venesection,  yet  the 
custom  spread  and  extended  in  France,  Italy  and  Spain 
unhindered  until  towards  the  end  of  the  sixteenth  century. 
All  the  protests  of  the  more  careful  physicians  and  learned 
bodies  did  less  to  stop  this  barbarous  practice  than  the 
satire  of  the  immortal  poet  Moliere  in  his  MaJade 
imaglnalre.  One  of  his  choruses  in  dog-Latin  runs  : 
"  Phlaebotomia,  dolum  medicorum,  nee  non  pontum 
asinorum  quia  ilia  ordinando  non  requiritur  magna 
scientia."     Le  Sage  also  at  a  later  day  wrote  a  satirical 

37 


THE  PEEVENTION  OF   DISEASE 

chapter  in  his  Gil  Bias  against  the  still  prevailing  evil. 
The  witty  Paracelsus,  in  Germany,  ridiculed  with  no  less 
scorn  the  unhappy  followers  of  Galen  who  thought  every 
one  had  too  much  blood.  He  does  not  condemn  it  alto- 
gether, but  brings  forward  some  astrological  reasons 
against  Galen's  arbitrary  practice.  About  this  time 
calendars  and  rules  were  drawn  up  by  physicians,  and  were 
used  till  the  beginning  of  the  nineteenth  century.  Besides 
weather  prognostications  there  were  also  rules  by  which 
could  be  found  the  day  on  which  blood  letting  should 
specially  be  performed.  The  oldest  book  of  the  kind  is  one 
by  Franz  Eapoldis,  Magnum  et  perpetuum  Almanack^ 
Antsverp,  1551,  but  David  Haarlich's  book  was  more  used 
and  more  pcnular. 

Harvey's  wonderful  discovery  brought  certain  modifica- 
tions into  the  practice  of  venesection,  and  the  contention 
as  to  which  part  of  the  body  should  be  selected  now  ceased. 
But  it  was  Helmont  and  his  great  reputation  which  checked 
this  thirst  for  blood  letting,  both  of  the  professional  and 
of  the  unprofessional  vampires. 

The  members  of  the  iatro-chemical  school  of  the 
seventeenth  century,  and  among  them  Anton  Fortius  at 
Rome,  were  enthusiastic  opponents  of  blood  letting.  The 
blood  is  free  from  pollution  and  blood  letting  cannot  there- 
fore improve  it,  and  plethora  does  not  exist  because  there 
is  too  much  blood  in  the  body,  but  because  the  blood  vessels 
are  weak.  If  the  contents  of  the  blood  vessels  is  with- 
drawn the  weakness  is  increased  and  not  diminished.  Only 
when  rupture  of  some  vessel  in  an  important  situation  is 
threatened  is  it  permissible  to  withdraw  blood.  Suitable 
diet  and  bodily  exercise  are  of  more  value  in  plethora  than 
is  blood  letting. 

In  opposition  to  the  iatro-chemists  were  the  iatro- 
physicists  who  favoured  venesection,  and  this  is  readily 
understood  when  we  remember  the  theoretical  idea  about 
the  nature  of  disease  held  by  this  school. 

In  the  beginning  of  the  eighteenth  century  a  great 
contention  arose  between  two  equally  well  known  and 
renowned   physicians,   Philip  Hecquet  and   Jean  Baptiste 

38 


THE   HISTORY   OF  THE   PREVENTION   OF   DISEASE 

Silva.  The  former  considered  venesection  one  of  the  best 
sedatives;  the  latter  maintained  that  the  sedative  effect 
could  be  obtained  by  far  less  dangerous  remedies. 

Sydenham  does  not  speak  in  favour  of  this  absurd 
reckless  and  dangerous  blood  letting,  but  uses  it  as  a 
pro23hylactic  when  acute  disease  threatens.  Yet  in  spite  of 
the  authoritative  utterance  of  this  great  man,  the  custom 
of  blood  letting  could  not  be  put  an  end  to ;  and  two 
opponents  in  other  matters,  Friedrich  Hoffmann  and  Stahl, 
joined  hands  in  energetically  recommending  venesection  as 
a  preventive  against  many  diseases.  It  is  probably  in  part 
due  to  the  influence  of  these  two  men  that  in  the  eighteenth 
century  almost  every  human  being  had  himself  bled  at 
least  twice  every  year,  and  that  in  addition  to  this  every 
pregnant  woman  was  bled  before  she  was  delivered. 
Venesection  survived  for  a  long  time,  and  was  fostered  by 
the  theories  of  Brown  in  England  and  of  Broussais.  It 
was  homoeopathy  and  the  moderate  Vienna  medical  school 
which  succeeded  at  the  beginning  of  the  nineteenth  century 
in  dealing  a  decisive  blow  at  this  harmful  custom. 

There  is  much  less  to  be  said  about  cures  by  purgation 
and  by  sweating  than  about  cures  by  blood  letting.  They 
were  generally  combined  with  blood  letting.  Purgation 
for  the  prevention  of  disease  is  a  very  old  custom,  both 
recommended  by  physicians  and  also  in  general  use  among 
the  people.  Hippocrates  recommended  asses'  milk  as  a 
mild  cure  of  this  kind.  It  is  probably  correct  to  assume 
that  these  suggestions  of  Hippocrates  did  not  undergo  any 
great  change  till  the  sixteenth  century,  although  asses' 
milk  was  sometimes  replaced  by  one  drug  sometimes  by 
another.  Paracelsus  ridiculed  these  methods  of  treatment, 
but  the  humours  recommended  by  him  are  probably  of  no 
greater  value  than  the  treatment  which  he  ridiculed. 
Helmont  is  also  an  opponent  of  purgatives.  They  can- 
not reach  the  "  archeus,"  which  is  the  cause  of  the 
corruption  of  the  juices.  On  the  contrary,  they  reduce  the 
strength  of  the  body  and  make  it  incapable  of  resisting  the 
"  archeus." 

The  iatro-chemical  school  indirectly  advocated  purgatives, 

39 


THE   PREVENTION  OF  DISEASE 

although  they  uttered  a  protest  against  purgative  treat- 
ment. For  fever,  which  they  regarded  as  the  expres- 
sion of  acidity,  they  ordered  alkalies,  and  all  of  these 
purge  more  or  less,  so  that  they  were  in  reality  practising 
that  treatment  against  which  they  protested.  Even  up  to 
the  present  day  purgation  in  treatment  plays  a  large  and 
important  role. 

Sweating  cures  have  already  been  referred  to  in  the 
section  upon  water  supply.  To  cut  short  the  illness  at  its 
beginning  not  only  were  baths  given,  but  many  hot 
beverages  to  cause  sweating  were  recommended,  such  as 
hot  lemonade.  Vapour  baths  were  employed  for  the  same 
purpose,  and  were  intended  to  rid  the  body  of  impurities. 
So  too  when  there  was  a  predisposition  to  rheumatic, 
gouty,  or  catarrhal  disease.  For  such  purposes  they  are 
still  extensively  used  at  the  present  day. 

There  are  also  many  articles  of  diet  and  medicinal  sub- 
stances which  are  valued,  not  altogether  without  reason, 
as  protective  against  certain  diseases.  Probably  every  race 
has  some  such  traditional  remedy  in  use,  and  it  would  be 
impossible  to  mention  them  all.  The  following  are  the 
most  common  among  them. 

We  find  the  Roman  writers  ridiculing  the  populace 
as  "  smelling  of  garlic."  Garlic  is  said  to  protect  against 
malaria,  and  it  is  also  said  to  protect  against  hydro- 
phobia and  the  bites  of  poisonous  insects,  as  well  as 
against  intestinal  worms.  How  far  this  popular  opinion, 
especially  common  amongst  the  southern  peoples,  rests 
upon  correct  observation  is  difficult  to  say. 

It  is  known  that  the  people  of  South  Russia  who  live  in 
malarial  districts  have  from  time  immemorial  prepared 
bitter  drinks  from  plants  which  grow  in  the  country,  to 
which  they  ascribe  virtue  against  malarial  infection. 
Saffron  was  regarded  by  the  ancient  races  as  a  valuable 
prophylactic.  How  old  the  custom  of  taking  alcohol  is  it 
is  impossible  to  say.  History  seems  to  show  that  every 
race  makes  use  of  some  intoxicating  drink  or  some  intoxi- 
cating substance.  Alcohol  especially  is  said  to  protect 
against  many  kinds  of  disease,  and  this  property  has  been 

40 


THE   HISTORY  OF   THE  PREVENTION   OF   DISEASE 

ascribed  to  it  from  time  immemorial.  Travellers  in  the 
tropics  say  that  it  has  always  been  renowned  as  a  pro- 
tective against  yellow  fever  and  dysentery.  Tobacco  is 
said  to  be  equally  valuable,  but  has  only  been  known  in 
the  old  world  since  the  discovery  of  America. 

Under  Louis  XIII  tobacco  came  to  be  used  as  snuif.  It 
is  said  to  have  the  property  of  protecting  against  several 
diseases.  It  is  claimed  that  it  relieves  the  brain  and 
thus  prevents  all  kinds  of  disease. 

Smoking  is  reported  to  have  been  introduced  among 
Spanish  navigators  about  the  middle  of  the  seventeenth  cen- 
tury. They  said  that  it  protected  against  various  diseases  at 
sea  and  also  in  foreign  countries.  Smoking  tobacco  has 
always  been  valued  as  a  prophylactic,  but  whether  this  is 
correct  must  be  left  undecided.  Sailors  still  chew  tobacco  to 
protect  themselves  against  scurvy.  It  is  well  known,  too, 
that  navigators,  especially  in  the  northern  seas,  look  upon 
acids,  particularly  citric  acid,  as  possessing  antiscorbutic 
properties. 

Among  drugs  which  are  still  today  much  prized 
as  popular  prophylactics  are  arsenic  and  quinine.  The 
latter  since  its  introduction  has  been  used  by  everyone 
going  to  a  malarious  district,  and  for  this  purpose  it  appears 
to  have  fully  deserved  its  reputation,  and  at  the  present 
time  we  know  of  no  other  drug  which  possesses  such  valu- 
able properties  as  cinchona  bark,  or  its  alkaloid  quinine.  In 
mountainous  districts  arsenic  has  from  time  immemorial 
been  used  to  prevent  debility.  The  inhabitants  of  some 
districts  (Steirmark,  Tyrol,  Salzburg)  give  very  small  doses 
of  arsenic  even  to  the  children  so  as  to  accustom  them  to 
the  poison.  The  dose  of  the  arsenic  is  then  increased,  and 
they  would  not  be  able  to  give  up  its  use  without  very 
injurious  results.  It  is  said  that  arsenic  increases  the  power 
of  work,  makes  climbing  of  mountains  easier,  and  prevents 
the  formation  of  goitre.  The  custom  of  eating  arsenic  is  a 
very  ancient  one.  History  does  not  say  who  first  introduced 
it  nor  when  it  was  introduced,  but  the  reputation  of  arsenic 
is  not  altogether  without  reason. 

The  value  of  bodily  exercise  in  the  prevention  of  disease 

41 


THE  PREVENTION   OF  DISEASE 

has  been  known  from  ancient  times  up  to  the  present  clay. 
We  need  only  mention  Haller  and  Vieth,  whose  works  give 
much  information  on  this  subject.  Later,  Rousseau  and 
Basedow,  basing  their  opinions  upon  this,  devised  reform  in 
education.  The  new  art  of  gymnastics  was  founded  by 
Simon  and  Guthsmuths.  The  latter  wrote  his  Gymnastics 
for  the  Young  in  1793,  and  the  modern  exercises  to  keep 
the  body  in  health  are  the  outcome  of  this. 


PART   III 

HISTOEICAL  ACCOUNT  OF  THE  PEEVENTION  OF  EPIDEMIC 

DISEASES 

Diseases  which  spread  from  man  to  man  and  diseases 
which  cling  to  certain  localities  have  always  given  rise  to 
public  and  private  precautions.  The  means  adopted  to 
prevent  these  diseases  varied  according  to  the  conception 
which  was  held  as-  to  their  nature.  The  idea  that  they 
were  of  demonological  origin  led  naturally  to  the  adoption 
of  demonological  means  such  as  magic,  amulets  and 
exorcism.  The  theological  theory  caused  religious  means 
to  be  used.  The  scientific  conception  of  diseases  and  of  their 
causes  led  us  to  adopt  dietetic  measures  for  prevention 
based  upon  scientific  facts.  Long  ago  the  distinction  was 
made  between  contagious  diseases  which  to  a  certain  extent 
are  indigenous  (endemic),  and  those  which  only  from  time 
to  time  visit  a  place  as  epidemics  and  then  after  a  time 
disappear  again.  The  former  have  been  and  are  still 
regarded  with  some  amount  of  indifference,  while  the  out- 
break of  an  epidemic  always  frightens  and  terrifies  the 
people.  Until  quite  recently  little  was  done  against  those 
terrible  endemic  diseases  scarlet  fever  and  diphtheria. 
Isolation  of  the  patient  and  inoculation  against  diphtheria 
are  of  very  recent  date,  while  long  ago  measures,  clumsy 
though  they  may  have  been,  were  nevertheless  used  against 
leprosy,  syphilis,  cholera  and  plague. 

42 


THE  HISTORY  OF  THE  PREVENTION  OF  DISEASE 


I.    SMALLPOX 

As  already  stated,  one  of  the  oldest  known  preventive 
methods  was  inoculation  against  smallpox.  Inoculation  to 
protect  against  smallpox  has  been  practised  in  China  and 
India  from  time  immemorial.  It  became  general  in 
Europe  only  a  century  ago.  Still,  even  without  con- 
sidering the  ancients,  here  and  there  preventive  smallpox 
inoculation  had  been  practised  by  dijfferent  peo^^les  in  Europe. 
Thus  for  example,  the  inhabitants  of  the  Caucasus  tried  to 
guard  their  children  against  disfigurement  by  smallpox.  In 
Denmark,  too,  in  various  districts  of  France  and  in  South 
"Wales  inoculation  against  smallpox  appears  to  have  been 
known  before  Jenner's  time.  In  South  Wales  the  operation 
was  known  as  "  buying  the  smallpox "  in  consequence  of 
the  belief  that  unless  the  person  furnishing  the  lymph 
received  some  recompense,  pecuniary  or  other,  no  result 
would  accrue.  An  English  physician,  Sulten,  tried  to 
improve  the  method  of  inoculation  by  taking  the  lymph 
from  the  pustules  of  patients  suffering  from  mild  smallpox 
and  conveying  it  to  the  arm  of  young  children  by  the 
lancet  point.  To  Sulten  is  due  the  credit  of  having 
exercised  great  care  in  inoculating  so  as  to  minimise  the 
danger  of  the  operation.  Of  17,000  children  whom  he  had 
inoculated  up  to  the  year  1767  only  six  or  seven  died  from 
the  inoculation.  This  inoculation  was  carried  out  in  some- 
what of  a  business-like  fashion  by  Sulten.  Everywhere  he 
had  agents  who  carried  out  his  method  with  good  results. 
The  results  were  so  brilliant  that  some  physicians  believed 
smallpox  had  altogether  disappeared  in  England.  Others 
believed  that  it  would  be  possible  to  prevent  an  outbreak  by 
giving  various  drugs.  For  this  purpose  Medicus  recom- 
mended quinine  ;  Vanderbock  and  Boerhaave  recommended 
antimony  and  mercury.  These  remedies  were  thought  to 
be  more  efficacious  than  prophylactic  inoculation.  Until 
the  eighties  of  the  eighteenth  century  Junker  and  Faust 
recommended  isolation  of  the  patient  as  the  best  means  for 

43 


THE  PREVENTION   OF  DISEASE 

checking  smallj)Ox.  Edward  Jenner,  a  medical  practitioner 
residing  at  Berkeley  in  the  vale  of  Gloucesterskire,  was 
led  towards  the  discovery  of  vaccination  by  the  casual 
remark  of  a  young  countrywoman  who  told  him  that 
milkmaids  were  immune  to  smallpox  infection  if  they 
had  been  accidentally  inoculated  with  cowpox  while 
handling  the  udders  of  the  cows  in  milking.  This 
statement  appears  to  have  made  a  profound  impression 
upon  Jenner's  mind,  and  after  much  inquiry  and  reflec- 
tion he  performed  his  first  vaccination  in  May,  1796.  The 
subject  was  James  Phipps,  a  boy  aged  eight,  who  was 
vaccinated  on  his  arms  with  matter  from  a  vesicle  on  the 
hand  of  a  dairymaid  who  had  been  infected  with  cowpox 
while  milking.  In  the  following  July  an  unsuccessful 
attempt  was  made  to  inoculate  Phipps  with  variolous 
matter.  Two  years  later  Jenner  published  his  memor- 
able Inquiry^  and  although  his  thesis  was  stoutly 
opposed,  and  some  want  of  success  attended  his  first 
efforts,  he  was  subsequently  able  to  establish  an  institute 
for  vaccination  in  London.  Soon  afterwards  a  similar 
institution  was  established  in  Berlin  by  the  celebrated  Heim. 
Others  were  established  in  Vienna  by  Johann  Carro,  in 
Geneva  by  Odier,  in  Hanover  by  Strohmeyer  and  Ball- 
horn.  It  is  surprising  that  the  strong  opposition  to 
vaccination  which  in  later  times  appeared,  and  at  the 
present  day  still  exists,  was  almost  unknown  when  these 
institutions  were  founded.  Protective  inoculation  with 
vaccine  from  arm  to  arm  spread  from  land  to  land,  and 
later  became  compulsory  in  most  civilized  countries.  A 
poet  wrote  in  1802 — 


So  raffb  fast  in  alien  Zonen 
Die  Blatternpest  mit  wilder  Hand 
Die  Mensclien  bin  zii  Millionen, 
Eh'  die  Vernunft  ein  Mittel  fand, 
Das  uus,  Avenu  man  so  weislicli  niit/t, 
Vor  diesem  Erdeniibel  schlitzt. 


44 


THE   HISTORY   OF  THE  PREVENTION   OF   DISEASE 

[In  almost  every  zone  smallpox  struck  clown  men  by  the 
million  till  a  means  was  found  wliicli,  wisely  used,  protects 
us  against  this  evil.] 

The  experience  of  the  Franco-German  war  showed  that 
although  protective  for  some  years  vaccination  loses  its 
protective  effect  after  a  certain  lapse  of  time.  And  then  in 
Germany  and  in  certain  other  countries  re- vaccination  in 
the  twelfth  year  of  life  was  made  compulsory.  Unfortu- 
nately we  have  no  similar  prophylactic  measures  against 
other  epidemic  diseases. 

Another  disease  against  which  prophylactic  measures 
have  been  usefully  employed  for  many  years  is  malaria. 
The  opinion  that  this  serious  disease  is  sometimes  con- 
tracted by  merely  breathing  the  air  of  malarial  districts 
is  now  known  to  be  incorrect,  as  it  as  been  shown  by  Koch 
and  others  that  malaria  is  conveyed  largely,  if  not  entirely 
through  the  instrumentality  of  certain  mosquitoes.  Though 
this  was  not  known  in  earlier  times,  yet  it  was  tolerably 
certain  that  malaria  was  confined  to  marshy  districts.  And 
many  of  the  ancient  civilized  races  endeavoured  to  drain 
the  marshy  ground,  and  thus  render  it  healthy.  Some 
historical  documents  show  that  such  efforts  to  drain 
districts  were  made  in  the  remotest  ages.  Reliable  in- 
formation about  this  matter  is  first  met  with  in  history  in 
connection  with  the  Pontine  Marshes.  A  large  plain  thirty 
to  forty  kilometres  long  and  eight  kilometres  broad,  lying 
to  the  south-east  of  Rome,  separated  from  the  sea  by  a 
tableland,  was  once  one  of  the  most  flourishing  districts. 
It  is  said  that  thirty-three  towns  stood  there  under  the 
Volscians.  Numerous  canals  drained  the  region,  and  fertile 
gardens  and  fruitful  fields  are  said  to  have  covered  it.  In 
the  year  358  b.  c.  the  Volscians  were  defeated  by  the 
Romans  after  several  sanguinary  battles,  carried  away  from 
their  homesteads  and  scattered.  From  that  time  the 
drainage  works  were  neglected.  The  houses  of  the  towns 
fell  in,  and  the  district  became  one  of  the  worst  in  Europe. 
In  spite  of  its  fertility  no  one  ventured  to  settle  down  there, 
for  he  would  undoubtedly  have  fallen  a  victim  to  the 
pestilence.  The  practical  Romans  did  not  fail  to  try  and 
restore  this  unhealthy  region  to  its  former  flourishing  con- 

45 


THE  PREVENTION   OF  DISEASE' 

dition.  It  was  thought  that  this  wonlcl  be  possible  by 
draining  the  Pontine  Marshes,  and  so  in  the  year  312  an 
attempt  was  made  to  provide  the  Via  Appia  with  a  system 
of  drainage.  These  works  were  carried  on  by  the  consul 
Cornelius  Cethegus,  by  Csesar  Augustus,  Nerva,  Trajan  and 
Theodoric  the  Great,  but  were  never  completed.  Eighteen 
popes  repeated  the  attempt,  but  always  with  insufficient 
money  and  technical  means.  Finally  Pius  VI  took  the 
work  in  hand  with  sufficient  means.  The  Via  Appia, 
which  in  the  meantime  had  completely  fallen  to  pieces,  was 
restored  at  an  outlay  of  7,000,000  lire.  He  built  a  long- 
canal  to  drain  it,  with  many  branch  ditches.  This  great 
effi^rt  was  indeed  crowned  by  some  measure  of  success. 
Part  of  the  devastated  plain  was  restored  to  cultivation, 
but  the  greater  part  of  it  lies  still  in  ruins  and  decay. 
Quite  recently  attempts  have  again  been  made  by  the 
Italian  Grovernment  to  improve  the  land  by  planting 
eucalyptus  trees. 

II.    LEPROSY 

V^e  have  already  seen  that  the  older  races,  especially  the 
Jewish,  sought  to  protect  themselves  from  leprosy.  The 
Old  Testament  tells  us  that  lepers  were  obliged  to  dwell 
outside  the  camp,  and  that  provision  was  made  for  them  so 
as  to  avoid  as  far  as  possible  all  intercourse  with  them.  The 
New  Testament  tells  how  the  Saviour  in  His  wanderings 
outside  the  town  and  in  the  vicinity  of  graveyards  came 
across  lepers  who  besought  Him  to  help  them.  The  Grreeks 
appear  not  to  have  been  familiar  with  the  worst  forms  of 
leprosy  (elephantiasis)  and  the  ulcerating  scabbed  form. 
It  would  appear  to  have  become  more  general  at  the  time 
of  the  Crusades.  Leprosy  was  in  the  middle  ages  what 
cholera  has  shown  itself  to  be  in  our  own  time,  "part  of 
that  force  "  which  "  makes  for  ill  but  works  good."  Not 
only  the  Crusades  but  other  historical  events  too  may  have 
assisted  the  spread  of  leprosy,  possibly  the  inroad  of  the 
Moors  into  Spain  and  the  migration  of  nations.  Although 
the  word  leprosy  occurs  frequently  in  the  records  of  the 

46 


THE  HISTOHY   OP   THE  PREVENTION  OP  DISEASE 

Arabians,  it  should  be  remembered  that  the  expression  is  a 
general  term  and  seems  to  denote  several  very  different 
diseases,  some  of  which  are  quite  innocent.  Among  the 
Lombards  special  hygienic  precautions  were  taken  against 
leprosy  during  the  reign  of  King  Rotthard.  The  unfor- 
tunate lepers  dwelt  in  special  places  outside  the  town.  They 
were  altogether  excluded  from  social  intercourse  and  to  a 
certain  extent  regarded  as  civilly  dead. 

Two  facts  about  the  way  in  which  leprosy  was  regarded 
show  extremely  well  the  character  of  the  middle  ages. 
On  the  one  hand  the  greatest  disregard  and  cruelty  were 
shown  to  lepers  ;  on  the  other  hand  a  romantic  enthusiasm 
was  evinced  for  these  lepers  by  those  who  saw  in  this 
plague  the  special  grace  of  God.  Both  views  led  to  the 
adoption  of  corresponding  prophylactic  measures.  Sprengel 
writes,  "  When  any  one  was  pronounced  to  have  leprosy, 
he  was  declared  civilly  dead  with  the  most  gruesome  cere- 
monies. Then  he  was  led  into  the  church  by  a  priest, 
exchanged  his  former  dress  for  a  black  garment,  and  upon 
his  head  and  breast  were  placed  two  woollen  bands  which 
were  visible  from  afar.  Then  a  requiem  was  said  as  at  a 
funeral.  The  priest  then  took  the  leper  into  a  house  which 
stood  alone,  cautioned  him  never  to  appear  in  public  in  any 
other  dress,  to  go  about  bare  footed,  and  to  avoid  wells, 
churches  and  bakeries.  Finally  a  shovel  full  of  earth  was 
thrown  over  the  bare  feet  of  the  leper.  The  leper  was  from 
that  moment  regarded  as  civilly  dead  (just  as  are  at  the 
present  day  those  who  are  of  unsound  mind)  and  could  not 
sue  at  law  or  inherit  or  acquire  property.  He  was  only 
permitted  to  touch  with  a  stick  anything  he  wanted  to  buy, 
and  as  he  went  along  he  always  made  a  noise  with  a  rattle 
to  give  warning  that  he  was  coming." 

It  is  evident  that  these  scandalous  rules  were  prompted 
by  a  desire  to  check  the  spread  of  the  disease,  but  like  all 
acts  of  cruelty  it  did  little  to  accomplish  its  end.  On  the 
contrary,  those  so  ignominiously  treated  were  often  em- 
bittered and  gave  vent  to  their  bitterness  by  rising  against 
their  hardhearted  oppressors  and  not  seldom  banded  them- 
selves together  with  other  classes  of  persons,  especially  the 

47 


THE  PREVENTION   OF  DISEASE 

Jews,  who  were  driven  to  desperation  by  the  injustice  of 
their  fellow  citizens. 

But  side  by  side  with  such  cruelties  other  measures  were 
resorted  to  as  the  outcome  of  the  romantic  tendency  of  the 
middle  ages.  We  have  already  said  that  some  believers 
looked  upon  the  lepers  as  people  specially  favoured  by  Grod. 
And  many  orders  were  founded  to  undertake  the  care  of 
lepers,  the  oldest  order  being  that  of  the  Knights  of  St. 
John,  established  in  the  seventh  century  by  merchants  in 
Amalfi,  A  document  dating  back  to  1311  is  still  in  exist- 
ence which  gives  information  about  the  organization  of  this 
order,  which  became  so  renowned  later  by  its  deeds  in  war, 
and  about  its  hospitals.  This  order  tried  to  moderate  the 
severity  of  the  civic  laws  against  lepers.  These  patients 
were  permitted  to  make  their  homes  within  the  borders  of 
the  institution.  They  were  permitted  to  marry  and  the 
married  couple  were  dowered  by  the  order.  Four  physicians 
looked  after  the  physical  welfare  of  the  patients.  The 
respect  felt  for  lepers  became  so  great,  that  in  time  the 
grand  master  was  always  selected  from  among  them. 

Thanks  to  the  influence  of  this  religious  order,  and 
possibly  also  from  fear  of  infection,  the  benevolence  of  the 
public  was  aroused,  and  everywhere  asylums  for  lepers 
were  established  called  leper  houses.  There  were  also 
smaller  huts  for  a  few  lepers,  the  so-called  stellae  and 
cucurbitae.  Out  of  these  institutions  have  arisen  a  large 
number  of  the  hospitals  and  infirmaries  of  the  present  day. 
Until  a  few  years  ago  the  general  hospital  in  Salzburg  bore 
the  inscription  "  Leper  House." 

III.    VENEEEAL  DISEASE 

There  is  no  certain  information  about  syphilis  until  the 
middle  ages,  when  the  disease  was  more  common  than  ever 
before  or  since.  If  it  is  permissible  to  form  an  opinion 
about  the  spread  of  the  disease  from  its  names,  this  loath- 
some disease  seems  to  have  been  carried  into  France  from 
Italy  (mal  de  Naples,  souvenir  de  Milan),  and  from  France 
into  Germany  (French  disease).     Whether  the  English  law 

48 


THE  HISTORY  OF  THE  PREVENTION   OF  DISEASE 

about  brothels  in  1126  and  its  revival  in  1430,  threatening 
the  brothel  keepers  with  a  fine  if  they  take  in  diseased 
women  and  ordering  a  regular  visitation  by  physicians, 
refers  to  syphilis  is  not  clear.  A  similar  order  issued  by 
King  John  of  Naples  is  regarded  by  some  historians  (Haeser) 
as  a  forgery. 

The  prevention  of  syphilis,  as  carried  out  today  in  all 
civilized  countries  except  England,  i.e.  regular  examination 
of  the  women,  does  not  date  back  further  than  the  French 
Revolution.  Brothels  have  existed  from  the  earliest  days 
and  were  under  strict  police  control,  but  whether  these 
were  established  for  sanitary  or  criminal  reasons  is  not 
evident.  And  of  what  use  was  an  examination  carried  out 
without  a  speculum,  and  this  has  not  been  in  use  a  hundred 
years  ?  History  shows  moreover  that  syphilis  has  been 
commonest  when  prostitutes  have  been  lodged  in  special 
houses,  so  that  this  appears  to  be  of  no  prophylactic  value. 
In  the  middle  ages  prostitution  was  sanctioned  even  by 
the  clergy,  and  alsa  taxed.  It  is  difHcult  to  say  whether 
this  encouragement  of  vice  by  laity  and  clergy  was  based 
upon  any  medicinal  and  prophylactic  idea. 

The  renowned  teacher  of  law,  Rittershausen  (who  lived 
1566-1613)  says  nothing  about  any  such  idea,  but  considers 
the  existence  of  such  houses  to  be  necessary  for  the  sake  of 
morality. 

Modern  advocates  of  prophylaxis  justify  these  degrading 
examinations  by  similar  reasons,  to  check  the  spread  of 
syphilis.  The  connection  between  syphilis  and  prostitu- 
tion which  is  medically  unregulated  was  recognized  in 
France,  so  that  at  the  time  of  the  French  Revolution 
regular  inspection  was  instituted  on  the  Continent  in  the 
same  way  in  which  it  was  already  being  carried  out  in 
England.  But  today  England  is  probably  the  only 
country  where  such  inspection  is  no  longer  made,  though 
it  is  carried  out  more  or  less  thoroughly  everywhere  else. 

Permission  to  maintain  houses  for  prostitution  has  some- 
times been  allowed  and  sometimes  been  refused,  but  always 
with  a  view  of  checking  syphilis.  In  Vienna  a  decree 
forbidding  such   houses  was  issued  under  Maria  Theresa, 

49  E 


THE   PREVENTION"  OF   DISEASE 

and  a  similar  law  was  made  iu  Berlin  in  1848.  Thus  it  is 
difficult  to  decide  wlietlier  the  true  idea  of  prevention  of 
syphilis  requires  the  closure  of  all  such  houses  or  not. 

Regular  inspection  in  the  army  and  navy  as  regards 
syphilis  commenced  in  England  and  has  been  in  force  in 
G-ermany  for  about  a  century. 

IV.    PLAG-UE 

This  terrible  pestilence  has  in  modern  times  only  been 
known  in  Europe  in  the  first  third  of  the  nineteenth 
century.  It  has  again  and  again  threatened  to  invade 
civilized  countries,  and  was  one  of  the  most  terrible  scourges 
in  past  centuries.  In  the  fourteenth  century  nearly 
25,000,000  people  were  swept  away  by  it  in  Europe.  Many 
towns  were  reduced  to  one  quarter  of  their  original  number 
of  inhabitants.  The  oldest  records  show  that  this  was  one 
of  the  most  terrible  of  pestilences.  Thucydides  and  Livy 
give  descriptions  of  it  which  are  among  the  most  terrible 
pictures  in  the  history  of  the  world.  And  later  Boccaccio 
has  also  described  it.  In  Thucydides  the  plague  broke  out 
during  the  Peloponnesian  war,  decimated  the  Grrecian  cities, 
especially  Athens,  and  reduced  the  fighting  capacity  of  the 
troops  so  gresitlj  that  it  required  all  the  eloquence  of 
Pericles  to  raise  again  the  spirits  of  his  countrymen.  It 
is  remarkable  that  the  historian  makes  no  mention  of  any 
prophylactic  measures  which  were  taken  against  the  disease. 
From  other  quarters  it  is  reported  that  Empedocles  adopted 
extensive  measures  against  the  plague.  When  there  was  a 
great  epidemic  he  had  large  fires  made  at  different  places  in 
the  towns  to  purify  the  air.  He  regarded  the  sirocco  as  the 
means  by  which  plague  was  spread,  and  therefore  wanted 
to  close  a  cleft  in  the  mountain  by  which  this  wind  came. 

Another  suggestion  made  by  the  same  physician  seems 
more  sensible  and  practicable  :  he  suggested  that  fresh  water 
should  be  carried  into  the  river  Hypsos  at  Selinos  to  remove 
the  miasmatic  effiuvia ;  but  it  is  doubtful  whether  this  was 
directed  against  plague  or  against  malaria.  In  the  whole 
Knass  of  Greek  literature  we  read  of  no  really  valuable 
attempt  to  combat  plague  epidemics.     This   attempt  was 

BO 


THE  HISTORY   OF   THE   PREVENTION  OF   DISEASE 

made  only  quite  recently,  and  to  explain  the  measures  which 
were  adopted  we  shall  refer  to  the  bubonic  plague  which 
recently  appeared  in  South  Europe. 

In  1812  it  appeared  in  Constantinople,  soon  afterwards  in 
other  towns  in  Turkey  and  Egypt.  In  one  year  some 
12,000  people  died  of  plague  in  Constantinople.  It  was 
carried  to  Odessa  by  ships,  and  3,000  out  of  a  population  of 
28,000  in  that  city  succumbed  to  the  disease.  At  the  same  time 
it  spread  from  Constantinople  to  Bucharest,  where  a  tenth 
part  of  the  total  population  of  80,000  fell  victims  to  plague. 
It  also  spread  from  Constantinoj)le  by  the  sea  to  Malta  and 
some  of  the  Grecian  islands.  In  Malta  it  carried  off  6,000 
people.  In  1815  the  plague  was  still  in  Turkey,  and  was 
conveyed  thence  to  the  east  coast  of  the  kingdom  of  Naples. 
It  broke  out  to  the  great  alarm  of  "Western  Europe  in  ISTaja, 
a  small  seaport  town  of  that  kingdom,  and  in  a  short  time 
killed  792  people. 

For  the  first  time  we  find  strict  prophylactic  rules.  The 
seaport  town  was  strictly  isolated,  and  moreover  those  ill 
with  plague  were  taken  to  well  supervised  quarantine 
buildings.  Ships  from  suspected  seaports  were  not  per- 
mitted to  enter,  and  goods  already  unloaded  were  disinfected 
by  exposure  to  superheated  steam.  These  rules  proved  to 
be  most  efficacious.  The  plague  was  not  only  stamped  out 
at  Naja  itself,  but  the  whole  of  Italy  and  the  greater  part 
of  the  west  of  Europe  escaped  the  infliction. 

Again,  in  1820  the  oriental  plague  appeared  in  the 
Balearic  Islands.  Majorca  alone  lost  2,000  persons,  Palma 
8,000.  The  experience  of  Naja  had  not  been  in  vain. 
Quarantine  regulations  were  adopted  against  the  infected 
islands  and  the  plague  stamped  out. 

In  1820  and  1829  cases  of  plague  appeared  again  in 
Moldau.  They  did  not  extend  far.  Here  and  there  smaller 
epidemics  appeared :  in  1872  in  South  Russia  ("Wetljanka)  ; 
in  1899  in  a  laboratory  in  Vienna.  But  each  time  it  was 
possible  by  strict  isolation  and  quarantine  to  master  the 
epidemic. 

Epidemics  of  plague  are  of  great  historical  interest 
in    civilization    quite    apart   from  medical  considerations, 

61 


THE  PEEVENTION   OE  DISEASE 

because  they  left  behind  them  the  utmost  desolation  in 
the  regions  they  attacked.  Sometimes  the  phj^sicians  were 
sacrificed  by  the  distracted  populace ;  sometimes  the  officials 
were  suspected  of  having  poisoned  the  wells  ;  sometimes 
the  malice  of  the  populace  was  directed  against  certain 
classes  of  the  people  who  had  escaped  the  plague.  Thus,  in 
the  sixteenth  century  a  rising  against  the  Jews  in  Cologne 
broke  out  as  the  result  of  the  plague,  because  the  Jewish 
quarter  had  been  little  attacked  by  plague.  In  one  day 
many  thousands  of  these  unfortunate  people  fell  victims  to 
the  fanaticism  of  the  populace,  and  the  authorities  were 
powerless  to  stem  the  tide  of  revolt.  In  1830  the  Jews 
were  slaughtered  in  Cracow  for  the  very  opposite  reason, 
because  in  an  epidemic  of  cholera  the  Jewish  quarter  of  the 
town  suffered  most.  Such  was  the  logic  of  the  people  and 
of  the  Grod-fearing  clergy. 

From  descriptions  of  the  plague  we  see  that  it  was  known 
in  the  nineteenth  century  to  be  spread  by  human  inter- 
course on  sea  or  on  land.  We  see  further  that  this  know- 
ledge led  to  the  adoption  of  very  stringent  but  also  very 
successful  measures.  More  recently  other  remarkable  facts 
concerning  the  spread  of  plague  have  come  to  light.  Re- 
search is  now  being  made  into  the  vital  processes  of  the 
plague  bacillus,  and  it  is  to  be  hoped  that  the  important 
knowledge  gained  in  the  various  laboratories  will  soon  enable 
preventive  inoculation  to  be  employed  successfully  in  relation 
to  this  disease.  It  is  scarcely  necessary  to  add  that  during 
the  middle  ages,  when  plague  was  regarded  as  a  punishment 
from  Heaven  for  the  wickedness  of  men,  attempts  were  made 
to  appease  the  wrath  of  the  Lord  by  prayers,  processions 
and  pilgrimages.     Much  greater  interest  is  felt  by  us  in 

V.    ASIATIC  CHOLEEA 

If  ever  a  scourge  of  God  has  prompted  mankind  to  good 
deeds  it  is  cholera.  It  is  largely  owing  to  this  scourge  that 
towns  are  nowadays  supplied  with  good  drinking  water  and 
with  a  regular  system  of  drainage.  The  scientific  work, 
too,  which  has  to  record  such  brilliant  results  during  the 
last  part  of  the  nineteenth  century,  is  also  connected  with 

52 


THE   HISTORY   OF   THE   PREVENTION   OF   DISEASE 

cholera.  Halier's  researches  in  bacillary  diseases,  Tiersch's 
experiments  in  -which  he  inoculated  white  mice  with 
cholera  excreta,  are  closely  connected  with  the  last  epi- 
demics of  cholera.  And  though  these  attempts  to  fight 
cholera  have  not  been  followed  by  any  great  result,  yet 
they  proved  a  stimulus  for  similar  work  in  other  diseases 
and  have  been  valuable  as  introducing  a  new  line  along 
which  science,  especially  medical  science,  can  travel.  It 
cannot  be  regarded  as  mere  chance  that  the  experiments 
of  Pasteur  and  of  Lister  followed  directly  upon  the  cholera 
epidemic  of  1866.  Indeed  if  we  look  at  the  development  of 
science  historically,  the  connexion  between  the  last  great 
epidemic  of  cholera  and  the  first  translations  of  Charles 
Darwin  into  German  will  not  escape  notice.  But  in  this 
place  we  shall  not  concern  ourselves  with  the  last  cholera 
epidemic,  when  opinions  as  to  the  spread  of  the  disease  were 
already  firmly  established,  but  with  the  first  which  visited 
Europe  to  any  great  extent. 

At  the  beginning  of  the  nineteenth  century  the  world  had 
already  fairly  well  advanced  in  science.  Protection  against 
epidemics  was  no  longer  sought  by  spiritual  and  ecclesias- 
tical measures.  The  knowledge  that  the  course  of  a  pesti- 
lence could  be  influenced  by  customs  and  habits  was  already 
widespread.  Physicians  and  reformers  tried  to  regulate  and 
improve  the  customs  of  the  people,  so  as  to  make  them  more 
in  consonance  with  the  principles  of  health.  The  State 
recognized  the  necessity  of  employing  physical  methods  to 
combat  physical  sources  of  ill.  Cholera  was  not  altogether 
unknown  at  its  first  appearance  in  Europe.  Writers  in 
classical  antiquity — Celsus,  Aretaeus,  Caelius — describe  an 
epidemic  disease  the  symptoms  of  which  agree  very  closely 
with  those  of  cholera.  Cholera  seems  also  to  have  been  in 
England  from  1669-72 ;  Sydenham  and  Willis  mention  it. 
Owing  to  the  extraordinary  lack  of  intercourse  of  those  days 
epidemics  spread  very  slowly  and  not  very  extensively. 

In  India  cholera  has  been  known  since  the  remotest 
ages,  though  it  is  limited  to  a  certain  district — the  delta 
of  the  Ganges.  In  1817  a  remarkable  increase  in  the 
mortality  from  this  disease  occurred  in  this  region.     The 

53 


THE  PREVENTION  OF  DISEASE 

small  town  of  Madia  first  attracted  tlie  notice  of  tlie  English 
Grovernment.  Thence  in  1817  cholera  spread  along  the 
Ganges  from  place  to  place,  from  town  to  town.  In  Jessore, 
a  somewhat  larger  town,  it  was  alarmingly  prevalent,  yet 
bnt  little  was  done  to  prevent  its  spread.  Not  till  it  reached 
Calcutta  and  carried  away  200  persons  every  week  (at 
that  time  the  population  of  Calcutta  numbered  600,000)  did 
the  English  Grovernment,  in  consequence  of  the  proximity 
of  one  of  its  garrisons,  begin  to  take  active  steps.  Still 
nothing  very  radical  was  attempted,  although  official  reports 
were  drawn  up.  For  two  years  cholera  continued  to  be 
epidemic  in  Calcutta,  and  thence  spread  to  the  neighbouring 
Sundas,  a  garrison  town  with  a  large  number  of  British 
troops,  of  whom  9,000  died  from  the  disease.  Then  the 
Government  ordered  the  removal  of  the  garrison.  They 
were  removed  to  the  mountains,  and  this  caused  the  dis- 
appearance of  the  disease  from  the  army.  But  from  the 
delta  of  the  Ganges  it  spread,  as  it  were  along  radii,  to  all 
parts  of  India.  Bombay,  Madras,  the  Coromandel  coast  and 
Ceylon,  lying  to  the  south  were  in  turn  invaded.  The 
epidemic  on  the  island  of  Ceylon  lasted  from  1819-23.  The 
disease  had  already  overspread  India.  Then  it  appeared 
in  Mauritius,  which  was  3,000  miles  distant,  and  6,000  per- 
sons succumbed  to  it. 

In  1820-1  it  reached  the  African  coast.  It  spread  also 
eastward  from  India  to  Sumatra,  Java,  Macao  and  China ; 
and  in  1821  it  appeared  at  Pekin.  From  India  it  spread 
also  to  Celebes  and  Manilla.  Rapid  intercourse  with  the 
East  quickly  took  it  to  the  rest  of  India  and  Arabia.  In 
1821  it  appeared  at  Bagdad,  and  spread  thence  along  the 
great  caravan  road  to  Alejopo  and  Syria.  It  spread  also 
from  India  north-west  across  Persia  to  Astrachan.  For  ten 
years  cholera  existed  unchecked  in  the  countries  outside 
Europe,  but  except  in  Astrachan,  where  its  progress  had  been 
checked,  Europe  had  till  then  escaped  cholera.  In  1830  it 
broke  out  in  Odessa.  Two  years  later  it  had  spread  over 
the  whole  of  Europe.  In  1832  it  had  invaded  central 
Germany,  France,  England,  Holland,  and  thence  spread  to 
the  United  States  of  America. 

54 


THE  HISTORY   OF   THE  PREVENTION  OF  DISEASE 

At  that  time  the  following  points  had  been  definitely 
established  in  connexion  with  prophylaxis — 

1.  The  ready  transmissibility  of  cholera  was  viewed  with 
alarm  and  was  known  to  be  connected  with  human  inter- 
course. Whether  it  could  be  spread  by  goods  was  not 
evident.  Whether  it  became  epidemic  in  every  place  to 
which  it  was  carried  seemed  at  least  doubtful.  For  some 
inexplicable  reason  some  towns  in  Europe  remained  free 
from  epidemic,  though  the  disease  had  undeniably  been 
introduced  into  them.  There  was  no  time  to  pause  for 
reflection.  The  expensive  method  of  quarantine  was  selected 
as  it  seemed  to  promise  the  best  results.  What  the  result 
was  we  shall  now  see. 

When  cholera  broke  out  in  1830  in  Eussia  it  appeared 
outside  Moscow.  Strict  quarantine  of  the  residents  was 
immediately  ordered,  and  as  it  seemed  with  success.  Dur- 
the  whole  of  the  quarantine  period,  extending  over  several 
months,  no  case  of  cholera  appeared  in  the  town  itself.  But 
this  calm  was  but  a  deception,  and  soon  there  followed  a 
bitter  disillusion.  In  spite  of  the  long  period  of  quarantine 
the  pestilence  broke  out  in  Moscow  and  thence  spread  along 
the  highway  towards  St.  Petersburg.  St.  Petersburg  was 
then  put  in  quarantine,  and  again  apparently  not  without 
success.  But  here  too,  as  in  the  case  of  Moscow,  cholera  broke 
out  a  few  months  after  the  quarantine  regulations  were 
removed.  The  political  conditions  of  Eussia  at  that  time 
were  the  most  favourable  which  could  have  existed  for  the 
spread  of  cholera.  The  last  embittered  revolutionary  war 
was  being  waged  by  the  Poles,  who  were  endeavouring  to 
throw  off  the  yoke  of  Eussia,  All  the  hardships  and  trials 
which  resulted  from  this  war  were  so  many  favourable 
factors  for  the  spread  of  cholera.  When  the  Eussian  columns 
crossed  the  Austrian  boundary  and  entered  Galicia  this 
pestilence  followed.  Galicia  became  a  hotbed  for  cholera. 
A  senseless  regulation  was  made  too  late,  and  quarantine 
against  Eussia  was  established  long  after  the  pestilence  had 
already  broken  out  in  Austria.  Taking  warning  by  Austria 
Prussia  established  an  extensive  military  cordon  to  cut  off 
communication  with  Eussia.     But  this  did  not  prevent  the 

55 


THE  PREVENTION   OF  DISEASE 

cholera  appearing  in  Dantzig  on  October  30,  1831.  Isola- 
tion of  Dantzig  also  proved  quite  ineffectual.  Cholera 
spread  thence  without  pause  into  the  heart  of  Germany 
through  Staluponen  and  Posen  to  Breslau,  and  then  to 
Madgeburg,  Halle  and  Berlin.  France  too  made  an  unsuc- 
cessful attempt  to  cut  off  communication  with  Germany. 
And  when,  in  spite  of  this  precaution,  cholera  broke  out 
in  Paris  this  costly  and  useless  attempt  was  abandoned. 

This,  briefly,  was  the  course  taken  by  the  first  epidemic 
of  cholera  in  Europe,  which  extended  over  so  long  a  period. 
Quarantine  and  other  regulations  to  isolated  places  had 
proved  to  be  almost  valueless.  Since  that  cholera  has 
often  invaded  Europe.  War  would  seem  to  be  the  condi- 
tion most  favourable  to  spread  cholera,  as  during  the 
sanguinary  war  between  Austria  and  Prussia  in  1866. 
But  the  lessons  in  prophylaxis  were  not  lost.  This  at  least 
is  certain  :  that  quarantine,  which  proved  to  be  so  effectual 
against  plague,  has  proved  to  be  almost  valueless  in  the 
case  of  cholera.  Pettenkofer  has  done  us  the  great  service 
of  showing  what  is  necessary  to  check  cholera.  Witli 
unwearied  eloquence  the  great  investigator  drew  attention 
to  the  fact  that  the  introduction  of  cholera  into  a  place  is 
only  dangerous  when  that  place  is  under  conditions  which 
are  favourable  to  the  development  of  cholera,  and  these 
conditions  are  sometimes  a  pestilential  soil  and  sometimes 
polluted  water. 

Next  we  come  to  the  present  period  in  the  history  of 
cholera,  and  with  this  ends  what  we  have  to  say  about 
the  history  of  the  prophylaxis  of  this  disease.  We  would 
only  add  that  the  most  recent  researches  in  the  laboratory 
would  seem  to  make  it  possible  for  each  individual  to  pro- 
tect himself,  for  a  time  at  least,  against  cholera. 

With  these  prophylactic  regulations  against  the  above 
mentioned  diseases  our  historical  material  is  exhausted. 
The  measures  adopted  to  prevent  typhoid  fever,  typhus, 
scarlet  fever,  diphtheria,  measles,  whooping  cough  and 
influenza  all  belong  to  quite  recent  times.  The  prophy- 
laxis of  pneumonia  and  tuberculosis  also  dates  back  less 
than    twenty   years,    though    Gerhard    told    us    at    the 

66 


THE  HISTORY  OF  THE  PREVENTION   OF  DISEASE 

International  Tuberculosis  Congress  in  Berlin  that  in  the 
eighteenth  century  regulations  had  been  issued  in  Italy 
and  Portugal  ordering  the  isolation  of  tuberculous  patients, 
forbidding  things  belonging  to  such  patients  being  sold  or 
given  away,  and  imposing  heavy  fines  on  physicians  who 
failed  to  notify  the  disease. 

The  prophylactic  rules  to  prevent  wound  infection  and 
puerperal  fever  are  of  older  date.  In  1869  in  the  Leipzig 
Clinic  the  first  trial  was  made  of  Lister's  antiseptic  method. 
This  was  a  very  elaborate  procedure  and  by  no  means 
applicable  to  all  operations.  Beneath  the  so-called  protec- 
tive, a  piece  of  linen  which  had  been  previously  dipped  in 
carbolic  oil  and  which  was  held  up  over  the  operating 
table  by  four  assistants,  the  part  of  the  body  to  be  operated 
on  was  first  well  washed  and  the  operation  then  performed. 
When  the  operation  was  over  the  protective  was  lowered 
and  placed  over  the  wound.  A  piece  of  tinfoil  was  smeared 
with  putty  containing  one  per  cent,  of  carbolic  acid,  and 
was  placed  over  the  wound  after  quickly  removing  the 
protective.  This  tinfoil  dressing  was  then  secured  by 
adhesive  plaster  and  bandages.  This  clumsy  and  awkward 
method  was  gradually  replaced  by  a  better,  and  antiseptic 
methods  have  become  aseptic  in  the  course  of  thirty  years. 
But  all  this  is  still  within  the  memory  of  the  present  genera- 
tion of  medical  men  and  need  not  be  further  detailed  here. 

In  close  connexion  with  the  prophylactic  treatment  of 
wounds  is  the  rational  method  by  which  lying-in  women 
are  protected  against  puerperal  fever  in  lying-in  institutions. 
The  absurd  theories  held  as  to  the  origin  of  puerperal  fever 
even  in  the  sixties,  and  the  opinion  that  this  terrible  disease 
could  be  prevented  by  costly  systems  of  ventilation  in 
lying-in  hospitals,  or  by  special  nourishment  during  the 
puerperium  or  even  by  purgatives,  have  all  been  overthrown 
since  the  introduction  of  antiseptics.  Although  Semmel- 
weiss  had  already  in  the  fifties  surmised  the  true  aetiology 
of  puerperal  fever,  although  Burow  had  introduced  into  his 
clinic  a  kind  of  antiseptic  method  long  before  Lister,  yet 
the  warnings  and  the  results  of  these  two  men  were  un- 
heeded.    Semmelweiss'  most  useful  life  ended  in  insanity 

57 


THE   PREVENTION   OF  DISEASE 

and  suicide.  And  tliongli  Burow's  end  was  not  a  tragic 
one,  yet  tlie  value  of  his  method  was  not  appreciated. 
These  facts  show  us  that  right  ideas  and  truths  are  not 
accepted  till  their  time  has  come.  In  the  case  of  the  anti- 
septic method  we  had  not  long  to  wait, 

KETROSPECT 

The  foregoing  shows  the  part  which  prophylaxis  has 
played  in  the  history  of  medicine.  It  has  closely  followed 
the  theoretical  ideas  held  about  disease.  It  forms  not  onlj'' 
a  part  in  the  history  of  medicine  but  also  in  the  history  of 
civilization.  "We  see  that  superstitious  and  religious  ideas 
as  well  as  scientific  ones  are  responsible  for  the  teaching 
about  prevention  of  disease.  Even  at  the  present  day, 
when  hygiene  is  doing  so  very  much  in  all  the  conditions 
of  life,  demonological  and  theological  views  as  to  the  origin 
of  disease  are  still  widely  held.  Just  as  certain  proverbs, 
sayings  and  fairy  tales  have  come  down  to  us  from  antiquity 
and  are  still  uttered  by  the  lips  of  children,  so  too  demopx)- 
logical  and  theological  precautions  still  enter  into  the 
childish  minds  of  the  people  in  spite  of  scientific  research. 
But  the  Government  measures  against  disease  are  no  longer 
based  upon  these  old  ideas.  A  well  devised  system  of 
prophylaxis  based  upon  scientific  knowledge  will  consist 
of  scientific  methods.  And  now  that  prophylaxis  has  fol- 
lowed the  lead  of  science  the  results  obtained  have  been 
very  important.  Probably  no  one  would  contradict  us  if 
we  said,  "Prophylaxis  during  the  last  half  of  the  nineteenth 
century  has  done  more  to  prevent  disease  than  all  that  it 
did  in  previous  centuries."  Nevertheless  the  knowledge 
gained  in  the  past  has  not  been  in  vain  and  useless  for  the 
present.  Just  as  a  venerable  tree  yearly  sheds  its  leaves, 
and  these  fall  over  its  roots  protecting  them  from  atmo- 
spheric influences  and  providing  nutriment  for  the  plant  by 
their  decomposition,  so  too  is  it  with  the  tree  of  knowledge. 
The  wrong  ideas,  the  errors,  are  like  the  leaves.  They  fall 
from  the  branches  but  protect  the  vitality  of  the  tree,  so 
that  for  many  successive  years  it  is  able  to  adorn  itself 
again  and  again  with  new  foliage 

58 


General     Prophylaxis 

BY 

PROFESSOR   MARTINS 

OF   EOSTOCK 


69 


General   Prophylaxis 

What  is  general  propliylaxis  ?  Prophylaxis  includes  the 
knowledge  and  the  methods  by  means  of  which  we  prevent 
or  at  least  endeavour  to  prevent  disease  ;  and  the  scope  of 
general  prophylaxis  is  the  scientific  inquiry  as  to  whether 
this  is  on  the  whole  possible,  and  in  what  way  it  may  be 
done.  The  aim  of  hygiene  however  is  similar.  What 
then  is  the  difference  ?  For  unless  there  is  a  difference,  in 
spite  of  the  similarity  of  their  aim,  we  shall  not  be  justified 
in  allowing  that  prophylaxis  is  a  branch  of  science  distinct 
from  hygiene. 

In  the  first  place,  what  is  hygiene  ?  Hygiene,  said 
Reich,  has  for  its  object  "  the  care  of  the  whole  physical 
and  moral  wellbeing  of  man,  both  individually  and  collec- 
tively, and  the  prevention  of  disease."  Accordingly  he 
regards  hygiene  "  as  the  philosophy,  science  and  art  of 
normal  life,"  and  draws  a  sharp  contrast  between  it  and 
"  the  modern  public  sanitary  authorities,  whose  main  object 
seems  to  be  the  cleaning  of  cesspools  and  disinfection." 
Unquestionably  this  work  too  is  beneficial  to  mankind,  and 
prevents  pestilences  and  much  misery.  But  it  is  not 
hygiene  :  it  is  not  the  bond  which  links  together  physicians, 
statesmen,  educationists  and  moralists ;  it  is  on  the  one 
side  applied  chemistry  and  physiology,  and  on  the  other  a 
matter  of  police  administration. 

In  contrast  to  this  "  general  Hygiene  "  endeavours  to 
advance  the  wellbeing  of  humanity  in  every  direction :  to 
influence  medicine,  education  and  religion,  to  improve  the 
customs  of  the  people  and  to  give  a  wholesome  impulse  to 
all  the  conditions  of  life. 

If  hygiene  were  that  bond  "  which  includes  all  who  are 

61 


THE  PREVENTION   OF  DISEASE 

working  for  the  welfare  of  mankind  and  all  who  are 
striving  after  knowledge,"  then  the  very  vastness  of  its 
aim  and  the  vagneness  of  its  task  would  frustrate  its  object. 
To  the  moral  reformer  who  believes  that  crime  and  vice 
may  be  lessened  by  mastering  the  passions,  the  disinfection 
of  cesspools  may  certainly  seem  work  of  little  value. 
Modern  hygiene  as  now  promoted  by  the  State,  represented 
in  all  universities  and  discussed  at  congresses,  is  entirely 
free  from  all  such  Utopian  aims.  It  is  an  applied  science, 
and  as  such  is  limited  to  the  physical  life  of  man,  and  has 
for  its  object  "inquiry  into  the  causes  of  disturbances  in 
health  and  of  disease,  the  prevention  of  these  disturbances, 
and  if  that  is  no  longer  possible,  the  removal  of  such  dis- 
turbances." The  difficulties  of  the  scientific  conception  of 
hygiene  arise  from  the  fact  that  it  is  not  always  easy  to 
draw  a  sharp  limiting  line  between  it  and  allied  subjects. 
If  the  object  of  hygiene  is  the  prevention  of  disease,  this 
presupposes  the  necessity  of  knowledge  of  the  way  in 
which  diseases  arise.  But  the  determination  of  the  causes 
of  disease  has  been  hitherto  the  domain  of  general  and 
experimental  pathology.  Is  this  now  to  be  transferred  to 
hygiene?  In  part  this  has  already  been  done.  The 
important  courses  of  bacteriology  are  given  in  Germany 
almost  without  exception  in  the  department  of  hygiene 
and  not  of  pathology ;  but  this  is  explained  by  the  historical 
development  of  this  youngest  branch  of  experimental 
pathology. 

Hygiene  is  indeed  and  will  remain  an  applied  science, 
without  any  methods  which  are  peculiar  to  itself.  Though 
hygiene  has  a  well  defined  area  within  which  physics  and 
chemistry,  physiology  and  pathology  work,  yet  each  of 
these  sciences  has  its  own  field  of  work  and  its  own  methods 
of  research.  Hygiene  has  to  do  with  all  these  fields  of 
science  and  accepts  the  methods  of  physical  as  well  as  of 
chemical  and  of  biological  research.  But  it  has  not  the 
task  of  forming  these  methods.  It  makes  use  of  all  these 
to  serve  its  own  purposes,  that  is  it  uses  them  exclusively 
to  promote  health  and  prevent  disease.  Now  that  we  know 
that  the  health  of  the  community  may  be  improved  by 

62 


GENERAL  PEOPHYLAXIS 

good  drainage  and  the  scavenging  of  towns,  the  architect 
and  the  administrative  officer  who  carry  these  out  have 
become  hygienists.  In  the  prevention  or  removal  of  ai,y 
pestilence  by  hygiene,  not  only  is  the  physician  needed  to 
show  what  is  the  nature  of  the  infectious  germ,  but  the 
State  and  lawmakers  must  make  regulations  which  shall 
prevent  a  spread  of  the  infection.  And  when  it  has  been 
shown  that  degeneration  of  the  race  may  be  prevented  by 
State  supervision  in  the  selection  of  individuals  fit  for 
marriage,  and  when  it  has  been  shown  that  improvement 
can  thus  be  brought  about,  then  there  will  necessarily  arise 
a  demand,  both  social  and  hygienic,  for  new  legal  regula- 
tions about  marriage. 

Even  if  we  abandon  Reich's  Utopian  ideas  of  improving 
the  whole  world  in  general  by  hygiene,  and  if  we  restrict 
hygiene  strictly  and  exclusively  to  the  realm  of  natural 
science,  its  scope  will  evidently  still  be  very  wide.  As  a 
social  science,  evolved  in  response  to  a  social  need,  it  is 
and  must  continue,  as  Hueppe  says,  to  be  social  hygiene 
or  else  not  exist  at  all.  It  is  of  service  in  maintaining  and 
in  improving  the  individual  type,  the  race  and  the  people ; 
and  its  task  is  a  far  greater  one  than  that  implied  by  the 
term  hygienic  when  this  is  used  to  express  merely  the 
medical  art  of  preserving  the  lives  of  weakly  or  diseased 
individuals.  Indeed  it  cannot  be  denied  that  here  there  is 
a  great  gulf,  a  dreadful  contradiction,  between  the  aims  of 
the  hygiene  of  the  individual  and  the  hygiene  of  the  race. 
By  hygiene  as  applied  to  an  individual  the  physician  strives 
to  improve  the  life  even  of  the  most  wretched  human  being, 
and  his  effi)rts  are  greater  the  more  feeble  is  the  individual ; 
but  the  hygiene  of  the  race  has  for  its  ultimate  aim  piti- 
lessly to  eliminate  those  of  weakly  constitution  and  thus 
to  improve  the  whole  people. 

The  solution  of  this  contradiction  is  the  hygienic  problem 
of  the  future.  If  indeed  the  watchful  care  which  is 
taken  to  protect  weakly  individuals  threatens  directly  the 
soundness  of  the  race,  the  question  may  arise  whether,  from 
the  standpoint  of  this  higher  social  hygiene,  the  philan- 
thropic movements  for  providing  institutions  for  the  weakly 

63 


THE   PREVENTION   OF  DISEASE 

and  crippled  and  so  interfering  with,  racial  selection  are  not 
an  evil.  Our  whole  ethical  sense  is  opposed  to  such  a  conclu- 
sion. There  must  be  some  solution  which  will  reconcile  the 
aims  of  the  hygiene  of  the  individual  and  the  hygiene  of 
the  race,  and  utilize  them  both  in  the  service  of  humanity. 
It  is  not  our  duty  here  to  find  this  solution.  It  was  only 
necessary  to  point  out  the  sharply  marked  difference 
between  the  two.  That  which  we  term  prophylaxis  is 
medicine  applied  to  the  improvement  of  the  individual ; 
this  alone  concerns  us  in  this  textbook.  The  far  greater 
and  more  extensive  task  of  social  hygiene — in  which,  in 
addition  to  physicians,  lawgivers,  government  officials  and 
engineers  are  engaged — lies  beyond  its  scope. 

In  this  limitation  lies  the  scientific  justification  for  a 
general  and  a  special  prophylaxis.  In  his  capacity  as  an 
individual,  as  a  citizen  and  a  lawgiver,  the  physician 
ought  to  make  himself  familiar  with  the  great  problems 
of  social  hygiene.  His  purely  medical  duties  are  however 
somewhat  different.  These  only  require  him  to  help  the 
individual  man  who  is  ill  and  to  guard  against  disease  the 
healthy  man  who  is  entrusted  to  his  care.  By  adopting 
these  limits  general  hygiene  and  general  prophylaxis  do  not 
come  into  conflict.  Tradition  says,  whether  correctly  or 
incorrectly  is  not  for  me  to  determine,  that  the  Chinaman 
pays  his  physician  only  so  long  as  he  remains  well.  The 
old  and  sensible  custom,  which  nowadays  is  dying  out, 
of  having  a  family  physician  was  based  upon  a  similar 
idea,  that  an  important  if  not  the  most  important  aim  of 
medical  skill  lay  in  individual  prophylaxis.  This  is  im- 
possible when  the  physician  is  paid  for  each  separate  visit 
to  the  family,  and  therefore  goes  only  when  expressly  asked 
to  call,  for  experience  shows  that  he  is  not  generally  called 
till  the  mischief  is  done. 

Individual  prophylaxis  should  commence  with  the  earliest 
training  of  the  child.  The  family  physician,  in  the  good 
old  sense  of  the  word,  knew  thoroughly  all  the  peculiarities 
of  the  family — both  the  good  and  the  bad.  Faithfully  and 
preseveringly  he  studied  the  special  disposition  of  each 
child.     Thus  he  could  assist  the  parents  by  warning  and 

64 


GENERAL  PROPHYLAXIS 

advising  them  about  the  child,  and  so  he  was  able  to 
nurture  the  delicate  little  human  plant  into  a  strong 
weatherproof  tree. 

The  more  this  useful  work  of  the  family  physician  is  lost, 
the  more  pressing  becomes  the  need  for  some  substitute. 
In  our  time,  with  its  socialistic  tendencies,  the  State  and  the 
community  are  undertaking  more  and  more  this  duty. 
"What  the  members  of  the  family  fail  to  do  is  done  by  the 
State.  And  more  than  this.  The  supervision  of  the  young, 
the  regulation  of  their  mode  of  life  and  conditions  of 
development  by  the  State  and  the  community  must  more 
and  more  become  such  that  it  will  be  permitted  to  inter- 
fere with  the  freedom  of  the  household  arrangements  when 
they  are  proved  to  be  unhygienic.  For  these  reasons  school 
physicians  will  be  necessary  in  the  future.  The  duty  of 
the  school  physician  will  be  to  see  that  general  hygienic 
measures  are  carried  out,  that  infection  is  prevented  from 
spreading  by  timely  isolation  of  the  patient,  that  the 
schoolrooms  are  supplied  with  sufficient  air  and  light, 
that  mental  and  physical  exercises  are  suitably  varied,  and 
so  on  ;  and  further  if  he  will  prove  truly  of  value,  he 
will  look  after  individual  prophylaxis  also,  because  one  plan 
is  not  applicable  to  all,  and  the  amount  of  mental  and 
bodily  exercise  which  may  be  regarded  as  a  normal  average 
may  be  for  some  individuals  a  harmful  excess. 

Medical  prophylaxis  is  accordingly  a  special  branch  of 
hygiene.  It  is  the  sum  total  of  medical  counsel  and  rules 
intended  to  protect  the  individual  against  disease.  In  this 
sense  medical  prophylaxis  guides  the  individual  through 
the  entire  course  of  life,  from  the  cradle  to  the  grave.  Just 
as  there  are  diseases  peculiar  to  the  infant,  to  the  school- 
boy and  to  the  old  man,  so  too  must  there  be  prophy- 
lactic measures  suitable  for  the  various  periods  of  life.  But 
these  too  must  be  modified  and  graduated  according  to  the 
need  of  any  individual,  otherwise  they  may  possibly  do 
harm  instead  of  good.  To  give  an  example :  it  is  true  that 
alcohol  is  nothing  less  than  a  poison  in  childhood,  while 
in  old  age  it  is  a  valuable  tonic  and  preservative.  Yet  in 
exceptional  cases,  in  acute  febrile  debility,  alcohol  may  be 

65  F 


THE  PREVENTION  OF  DISEASE 

a  useful  medicine  for  tlie  cliild,  and  on  the  otlier  hand,  when 
there  is  arterio-sclerosis,  and  a  tendency  to  apoplexy,  it  may 
be  a  poison  to  the  old  man.  In  the  prevention,  as  in  the 
question  of  production  of  disease,  we  must  take  into  con- 
sideration the  personal  factor. 

Individual  prophylaxis  assumes  complete  knowledge  of 
the  mode  of  origin  of  disease  in  the  individual.  The  whole 
history  of  medicine  shows  that  it  has  always  been  believed 
that,  under  precisely  similar  conditions,  of  two  individuals 
one  may  fall  ill  while  the  other  will  remain  well.  Hence 
it  follows  that  general  pathology  which  is  based  essentially 
upon  an  experimental  foundation,  and  studies  the  laws  of 
the  injurious  effects  produced  by  harmful  agents  upon  all 
members  of  the  same  class,  is  unable  to  explain  the  cause  of 
every  case  of  disease.  Disease  may  in  some  cases  often  be 
produced  by  conditions  which  are  not  general,  that  is  they 
would  not  produce  disease  in  every  individual  without 
exception.  This  can  only  be  explained  by  the  existence  of 
some  causal  factor  in  that  case  which  is  not  common  to  all 
the  members  of  the  class.  All  such  individual  factors 
which  are  inherent  in  the  cells,  tissues,  or  organs  are 
termed  constitutional.  Whether  this  constitutional  causative 
factor  of  disease  be  inherited  or  acquired,  it  must  never  be 
omitted  from  our  consideration  of  the  production  of  disease, 
unless  we  have  to  deal  with  an  injury  which  is  so  severe 
and  dangerous  that  no  life  or  organic  structure  could  resist 
it,  such  as  traumatic  destruction  of  the  tissues,  severe 
poisons  and  very  virulent  infections.  These  general  causes 
of  disease  can  only  be  prevented  by  one  method  of 
individual  prophylaxis — their  avoidance.  The  man  who 
does  not  want  to  be  wounded  should  do  his  best  to  avoid 
going  to  a  place  where  there  is  shooting.  He  who  lives  in 
a  district  which  is  perfectly  free  from  malaria  and  cholera 
will  not  get  these  diseases.  This  is  so  clear  and  self-evident, 
that  it  might  seem  as  if  the  battle  against  external  causes 
of  disease  were  alone  worth  waging  and  were  the  only 
possible  way  in  which  disease  could  be  prevented. 

The  history  of  vaccination  has  already  shown  that  this  is 
a  complete  error.      That  terrible  pestilence,  smallpox,  has 

66 


GENERAL  PROPHYLAXIS 

almost  completely  disappeared  from  among  us,  not  because 
we  have  discovered  and  destroyed  the  exciting  cause  of 
smallpox — which  indeed  is  still  unknown — and  have  thus 
prevented  its  spread  in  the  world,  but  solely  because 
we  have  succeeded  in  making  every  individual  personally 
proof  against  this  pestilence.^  The  application  of  this 
principle  to  other  infective  diseases  marks  one  of  the 
greatest  advances  in  modern  medicine.  There  are  there- 
fore two  methods  by  which  we  may  prevent  or  overcome 
infectious  disease.  We  can  prevent  such  disease  either 
by  destroying  the  exciting  cause  of  the  disease,  by  making 
it  innocuous,  by  keeping  it  from  coming  into  contact  with 
individuals,  or  by  a  method  which .  will  strengthen,  fortify 
and  immunize  those  who  are  exposed  to  the  disease.  In 
epidemics  of  diseases  coming  from  abroad,  such  as  cholera  and 
above  all  plague,  we  endeavour  *to  protect  ourselves  solely 
or  almost  solely  by  restricting  intercourse  with  infected 
people.  We  try  to  prevent  the  exciting  cause  of  the  disease 
from  entering  our  country,  and  when  in  spite  of  all 
precautions  the  disease  has  nevertheless  made  its 
appearance,  we  isolate  the  individual  affected  and  thus 
prevent  further  spread.  In  endemic  infective  diseases,  such 
as  tuberculosis,  diphtheria,  the  acute  exanthemata  and 
typhoid,  this  method  by  itself  is  insufficient.  To  close  the 
gate  of  the  town  is  of  no  avail  because  the  enemy  is  already 
within  the  walls.  In  such  a  case  we  may  yet  succeed  if  we 
remove  the  conditions  necessary  for  the  existence  of  the 
enemy  which  has  already  entered.  Munich,  Dantzig  and 
Berlin,  formerly  hotbeds  for  typhoid  fever,  have  been 
almost  completely  freed  from  the  disease  by  drainage. 
Wherever  the  exciting  causes  of  the  disease  are  known  to 
exist  adequate  measures  must  be  taken.  The  destruction  of 
tuberculous  sputum  by  the  patient  himself  is  a  social 
duty  which  is  owing  to  humanity,  and  the  State  will  have 
to  consider  how  far  it  is  justified  in  insisting  upon  the 
isolation  of  patients  with  infectious  disease  without 
unduly  interfering  with  household  arrangements. 

1  This  applies  to  Germany  rather  than  to  Great  Britain.     [Trans- 
lator.] 

67 


THE  PREVENTION  OF  DISEASE 

But  all  these  measures  belong  to  general  or  State 
hygiene.  What  then  is  the  work  of  individual  medical 
prophylaxis  ?  There  remains  for  it  a  wide  and  most  useful 
field  of  work  in  strengthening  and  fortifying  the  individual 
himself.  Immunization,  as  is  evident  in  connection  with 
smallpox,  can  be  carried  out  by  the  State.  But  at  the 
present  time  smallpox  is  still  the  exception.  To  bring  up 
a  weakly  child  who  may  also  be  hereditarily  tainted,  so 
that  it  does  not  succumb  to  the  threatening  danger  of 
tuberculous  infection,  is  individual  medical  prophylaxis. 

This  is  the  more  true  when  we  deal  with  diseases  in 
which  the  constitutional  factor  predominates,  and  the 
exciting  cause — the  so-called  "  external  cause  " — is  a 
minor  one.  The  large  group  of  functional  neuroses  and 
of  diseases  of  metabolism  belong  to  this  class.  The 
greater  the  predisposition,  the  less  the  exciting  cause 
which  suffices  to  produce  the  disease.  The  common 
causative  factors  peculiar  to  any  disease,  that  is  those 
which  would  cause  disease  in  an  individual  of  average 
strength,  do  not  exist  in  these  cases.  Tubercle  bacilli 
and  alcohol  are  both  causes  of  disease,  and  there  is  a 
strong  agitation  against  both.  Yet  it  would  be  radically 
wrong  to  estimate  them  alike,  so  far  as  concerns  the 
production  of  disease.  Alcohol  is  a  poison  only  when 
taken  in  a  given  quantity,  and  this  quantity  is  very 
different  for  different  individuals.  One  with  a  congenital 
tendency  to  neurasthenia  will  not  be  able  to  take  the 
amou.nt  of  alcohol  which  for  the  healthy  man  is  a 
harmless  and  pleasant  stimulant :  and  individual  prophy- 
laxis must  take  this  into  consideration. 

And  what  is  true  of  alcohol  is  also  true  for  other 
stimulants  and  pleasures :  for  tobacco,  tea  and  coffee,  and 
for  sports,  sexual  intercourse  and  mental  exertion.  The 
duty  of  the  physician  is  to  estimate  the  relative  amount 
which  in  any  particular  individual  would  cause  disease. 

But  how  can  this  relative  estimate  of  the  specific 
tendency  to  disease  be  made  ?  This  is  a  weighty  problem, 
and  upon  the  answer  the  possibility  of  individual  pro- 
phylaxis in  a  scientific  sense  will  stand  or  fall. 

68 


GENERAL  PEOPHYLAXIS 

Many  pathologists  whose  work  is  concerned  with 
"  external "  causes  which  under  all  circumstances  produce 
pathological  changes,  only  make  use  of  the  term  predis- 
position when  they  have  nothing  else  upon  which  to 
fall  back.  It  must  be  confessed  that  the  vague  expres- 
sions, a  weak  or  a  strong  constitution,  a  lymphatic  or 
an  arthritic  diathesis,  do  not  help  us  much ;  because  gene- 
rally the  diagnosis  of  such  a  condition  in  any  individual 
is  only  possible  after  the  disease  has  shown  itself.  When 
we  say  that  one  who  suffers  from  liver  disease  has  a 
bilious  constitution,  or  that  one  who  has  had  an  attack  of 
cerebral  haemorrhage  has  an  apoplectic  tendency,  the 
statement  is  quite  valueless.  That  is  evident  directly  we 
think  at  all  about  individual  prophylaxis.  The  history  of 
medicine  tells  of  many  different  attempts  to  put  this 
ancient  vague  idea  of  a  constitutional  tendency  into  some 
definite  exact  terms.  Mostly  an  anatomical  basis  was 
chosen.  Beneke  worked  it  out  into  a  system  thirty  years 
ago  from  this  standpoint.  He  determined  the  relative  size 
of  organs  in  various  constitutions  by  measuring  and 
weighing  them  after  death,  and  looked  upon  these 
measurements  as  exact  expressions  of  those  constitutions. 
This  laborious  work  of  Beneke's  has  been  quite  useless, 
and  the  reason  of  this  is  evident  from  a  consideration  of 
the  subject  of  individual  prophylaxis.  When  a  person's 
constitution  makes  him  especially  liable  to  contract  any 
disease  and  we  desire  to  protect  him  from  this  danger 
by  regulating  his  manner  of  life,  and  by  keeping  him  away 
from  sources  of  specific  infection,  the  measurement  of  the 
length  of  his  intestine  and  the  width  of  his  arteries 
and  the  volume  of  his  heart  and  lungs  after  death  are 
entirely  useless.  Moreover  it  is  less  a  question  of  the 
relative  size  of  his  organs  than  of  their  relative  functional 
capacity.  And  the  individual  variations  in  this  can  be 
determined  for  most  organs  before  the  disease  sets  in,  by 
exact  physical  and  chemical  examination.  This  is  the 
method  towards  which  clinical  medicine  now  points.  It 
is  purely  clinical.  The  individual  and  the  special  ten- 
dencies of^  his  organs  are  themselves  carefully  studied  and 

69 


THE  PREVENTION  OF  DISEASE 

considered.     It  is  most  useful  because  it  enables  us  to  draw 
up  a  scientific  scheme  of  exact  individual  prophylaxis. 

The  physician  for  mental  diseases  is  for  the  most  part 
accustomed  to  take  into  consideration  great  and  definite 
differences  in  the  personal  predisposition  of  his  patients. 
The  brain  is  the  most  highly  developed  and  therefore  the 
most  highly  differentiated  organ  in  the  human  body.  It  is 
a  well  established  fact  that  this  differentiation  has  its 
material  substratum.  But  this  is  scarcely  perceptible 
anatomically.  Whether  the  attempt  by  Mobius  to  revive 
Gall's  phrenology  will  be  of  any  use  remains  to  be  seen. 
For  the  present  we  fall  back  upon  determining  the 
functional  capacity,  and  this  can  be  done  very  exactly. 
A  well  trained  teacher — unfortunately  they  are  not  all 
so — knows  well  the  specific  "  tendencies  "  of  his  scholars 
and  takes  them  into  consideration.  Such  specific  ten- 
dencies may  also  be  negative.  There  may  be  con- 
genital functional  inferiority  of  will-power,  of  feeling, 
or  of  intellect.  Individual  prophylaxis  by  physician  and 
by  teacher  is  then  called  for.  Unfortunately  "  individual- 
ization "  in  this  sense  conveys  to  many  no  meaning.  The 
time  will  come  when  individual  prophylaxis,  founded  upon 
scientific  observation  and  determination  of  functional 
capacity,  will  play  an  important  part  in  teaching. 
Theoretically,  at  least,  individualization  would  appear  to 
be  taken  into  consideration  in  the  treatment  of  patients, 
if  we  can  believe  the  prospectuses  of  the  numerous 
dietetic  institutions  and  institutions  for  the  cure  of 
nervous  disease.  But  how  is  it  really  in  practice  ?  How 
oan  such  individualization  be  learned,  while  the  pathology 
and  treatment  taught  at  the  universities  are  exclusively 
general  pathology  and  treatment — that  is  while  students 
are  taught  what  is  true  only  about  the  average  human 
being  ?  Take  as  an  example  the  effect  of  drugs.  Our 
knowledge  of  them  is  their  typical  effect :  that  is  their 
effect  on  the  average  normal  man.  Individual  deviations 
from  this  type,  and  the  by-effects  systematically  studied 
by  Lewin,  are  regarded  by  most  physicians  merely  as 
interesting  curiosities,  and  are  put  down  to  "idiosyncrasies." 

70 


GENERAL  PROPHYLAXIS 

Yet  they  are  of  immense  scientific  value  in  the  study  of  the 
production  and  prevention  of  disease  in  the  individual. 
Striking  and  great  deviations  from  the  typical  action  of 
drugs  met  with  in  certain  individuals,  such  as  intolerance 
of  alcohol,  morphine,  antipyrin,  or  iron,  show  that  there 
is  some  abnormal  nervous  predisposition  which  the  physician 
should  take  into  consideration,  not  only  in  the  treatment 
but  also  in  the  prevention  of  disease.  The  modern  trained 
physician  for  nervous  diseases  has  long  been  accustomed  to 
be  very  cautious  in  prescribing  the  various  so-called  nervines 
to  his  patients,  and  conversely  the  appearance  of  any 
so-called  idiosyncrasy  in  a  patient  would  be  to  him  a  sign 
of  a  special  nervous  diathesis. 

The  alcohol  question,  which  is  becoming  more  and  more 
urgent,  can  neither  be  understood  nor  solved  apart  from  the 
view  of  the  production  of  disease.  There  are  individuals 
with  badly  developed  nervous  systems  to  whom  alcohol  is 
an  absolute  poison,  but  to  wish  to  deprive  the  large  majority 
of  men  of  alcohol,  though  their  nervous  systems  are  strong 
enough  not  to  be  injured  by  a  moderate  use  of  wine,  a 
harmless  and  therefore  an  excellent  stimulant,  would  be 
to  throw  away  the  good  with  the  bad.  Conversely  he  who 
does  not  yet  know  how  injurious  even  a  moderate  use  of 
alcohol  is  to  children  and  to  those  with  a  tendency  to 
neurasthenia  cannot  claim  to  have  any  knowledge  of 
prophylaxis. 

That  favourite  catchword,  "  individualization,"  is  at  the 
present  time  even  more  meaningless  when  applied  to  weak 
conditions  of  other  organs  than  when  used  of  functional 
neuroses.  Yet  in  most  cases  hereditary  inefficiency  of  other 
organs  may  generally  be  determined  by  a  careful  estimation 
of  their  functional  capacity  even  before  it  has  given  rise  to 
any  real  disease.  A  scientific  prophylaxis  is  only  possible 
when  we  know  what  special  organic  weakness  is  present, 
that  is  what  individual  predisposition  to  disease  exists.  A 
great  and  far-reaching  task  is  before  us  in  this  field  of 
clinical  inquiry,  in  which,  equipped  with  all  the  means  of 
modern  scientific  methods,  we  endeavour  to  determine  from 
what  diseases  an  individual  who  is  still  healthy  will  be 

71 


THE  PREVENTION   OF  DISEASE 

likely  or  liable  to  suffer.  The  proof  that  there  is  a  con- 
stitutional albuminuria  or  glycosuria  may  be  taken  as  a 
typical  example.  Those  who  desire  further  information 
about  this  subject  and  about  the  problems  still  to  be  solved 
are  referred  to  the  fourth  chapter  of  my  book,  "  The  Pro- 
duction of  Internal  Diseases  "  (Vienna,  1900). 

One  other  question  arises.  Some  causes  of  disease  can  be 
got  rid  of  and  banished  from  the  world.  Is  it  possible  also 
to  avoid  predisposition  to  disease  ?  That  is  the  question 
and  it  is  obviously  quite  different  from  the  question  pre- 
viously put,  namely  how  the  outbreak  of  a  disease  may  be 
prevented  for  which  there  is  an  hereditary  predisposition. 
To  answer  the  question  we  need  to  know  whence  came  the 
predisposition,  how  it  arose,  and  what  conditions  and  factors 
caused  its  development.  We  distinguish  between  acquired 
and  inherited  predispositions  to  disease.  The  former  arise 
through  external  causes  which  are  also  the  causes  of  real 
diseases.  Measles  and  influenza  "  predispose "  to  tuber- 
culosis, and  so  too  does  diabetes.  Tabes  dorsalis  and 
general  paralysis  of  the  insane  develop  in  a  syphilitic  con- 
stitution. Prophylaxis  for  the  prevention  of  such  acquired 
predispositions  coincides  with  prophylaxis  of  the  predispos- 
ing illness  itself.  Whatever  opinion  one  may  hold  about 
the  connexion  between  syphilis  and  locomotor  ataxia,  it  is 
certain  that  an  individual  who  has  not  had  syphilis  will  be 
far  less  likely  to  have  tabes  than  one  who  has  formerly  had 
syphilis.  The  direct  prophylaxis  of  syphilis  is  also  an  in- 
direct prophylaxis  of  tabes.  But  when  the  syphilitic  consti- 
tution is  already  present,  and  there  is  therefore  an  acquired 
predisposition  to  tabes,  special  prophylaxis  is  required  to 
prevent  locomotor  ataxia.  Syphilis  greatly  reduces  the 
resisting  power  of  the  peripheral  sensory  neurones  against 
external  injuries  such  as  colds  and  excessive  strains.  One 
who  has  been  infected  with  syphilis  should  therefore  be- 
ware of  exposing  himself  to  such  injurious  conditions,  and 
this  may  be  a  matter  of  considerable  importance,  for 
instance  in  connexion  with  campaigns.  A  predisposition  to 
a  disease  will  be  much  more  serious  when  the  predisposition 
has  not  been  acquired  by  the  action  of  any  external  in- 

72 


GENERAL  PROPHYLAXIS 

jnrious  causes.  It  is  then  generally  termed  congenital  or 
hereditary.  Many  physicians  regard  the  two,  congenital  and 
hereditary,  as  identical,  and  this  is  much  to  be  regretted  as  it 
leads  to  want  of  clear  clinical  judgment.  It  is  obvious  that 
anything  which  is  congenital  must  in  some  way  have  been 
inherited,  that  is  it  comes  from  the  parents.  The  term 
hereditary  is  however  often  not  used  in  this  general  sense. 
"We  are  accustomed  to  speak  of  hereditary  disease  only  when 
it  can  be  shown  that  one  or  more  ancestors  have  suffered 
from  the  same  disease.  This  want  of  precision  leads  on  the 
one  hand  to  the  denial  of  any  predisposition  to  tuberculosis 
in  a  tuberculous  patient  whose  parents  or  grandparents 
were  free  from  tuberculous  disease,  and  on  the  other  hand 
makes  us  speak  of  an  epileptic  tendency — say  in  an 
epileptic — because  an  aunt  only  happened  to  be  epileptic. 
Both  are  unreliable  statements.  The  first  fact  is  not 
sufficient  to  exclude  a  specific  predisposition  in  that 
individual,  nor  the  second  sufficient  to  establish  such  a 
predisposition.  The  problem  of  heredity  in  pathology 
suffers  from  a  confusion  of  ideas  which  can  here  be  only 
briefly  referred  to  and  cannot  be  fully  discussed.  The 
principal  points  to  be  considered  in  heredity  are  probably 
as  follows — A  "disease"  is  never  inherited.  To  hold  such 
a  view  would  be  an  unscientific  return  to  a  theory  of  disease 
which  was  abandoned  long  ago.  Disease  is  not  a  "  thing," 
it  is  neither  an  object  nor  a  property,  but  it  is  a  process 
which  developes  and  progresses  upon  a  given  substratum. 
Neither  epilepsy  nor  phthisis  can  be  demonstrated  on  the 
dead  subject  or  stained  for  the  microscope,  or  grown  as 
a  pure  culture.  "What  we  see  is  the  organ  which  has  been 
attacked  by  the  disease,  the  anatomical  and  histological 
changes  brought  about  in  the  organ ;  and  we  can  see  the 
external  exciting  cause  of  the  process.  If  the  child  is 
born  with  well  marked  anatomical  changes,  then  we  have  a 
case  of  disease  of  true  intra-uterine  development.  A  child 
with  congenital  syphilis,  which  is  born  with  evident  signs 
of  syphilitic  disease,  has  suffered  intra-uterine  infection.  The 
disease  is  congenital.  But  this  process  has  nothing  to  do 
with  the  problem  of  heredity.      It  is  hardly  different  when 

73 


THE  PREVENTION  OF  DISEASE 

a  child  is  born  apparently  healthy — that  is  so  far  as  we  can 
judge — or  really  healthy,  then  later  it  becomes  ill  without 
any  apparent  external  cause.  In  the  case  of  microbic 
diseases  there  is  then  the  possibility  that  the  exciting  cause 
of  the  disease  (the  tubercle  bacillus  or  the  unknown 
microbe  of  syphilis)  was  born  with  the  child,  though  it  had 
not  yet  become  possible  for  it  to  cause  any  pathological 
effects,  and  this  possibility  occurs  only  in  extra-uterine  life. 
Such  cases  are  rare  but  they  do  occur,  for  example  in 
tuberculosis.  But  this  knowledge  does  not  in  any  way  aid 
in  solving  the  problem  of  heredity.  In  this  instance  also 
it  is  obviously  a  case  of  intra-uterine  infection.  Indeed 
these  cases  need  not  to  be  separated  from  the  former  where 
intra-uterine  infection  had  produced  intra-uterine  disease. 
This  fact  needs  to  be  emphasized  in  any  discussion.  That 
the  true  problem  of  heredity  is  not  touched  by  the  question 
as  to  whether  and  how  far  we  are  to  accept  the  fact  of  an 
intra-uterine  infection,  will  be  evident  when  we  remember 
that  the  chief  hereditary  diseases  are  not  infective  diseases. 
What  is  it  that  is  transmitted  by  heredity  in  mental  and 
nervous  diseases,  in  diseases  of  metabolism,  or  in  the  so-called 
constitutional  diseases  which  are  justly  termed  hereditary  ? 
It  is  merely  a  certain  weakness  of  some  organ  or  tissue,  a 
specific  kind  of  vital  inefficiency  which  renders  that  organ  or 
structure  more  susceptible  to  external  injurious  influences 
than  is  a  normal  organ.  That  there  is  such  a  congenital 
specific  inferiority  of  various  structures,  organs  or  systems 
in  the  body  has  been  shown  by  clinical  experience  for 
over  a  thousand  years,  and  can  also  be  proved  in  an 
individual  by  careful  examination  of  his  functional 
capacity.  The  question,  to  put  it  briefly,  is  whether 
such  predisposition  to  disease  is  and  must  be  inherited,  and 
what  are  the  conditions  under  which  it  is  transmitted. 
Such  is  the  scientific  problem  of  heredity,  upon  the 
solution  of  which  alone  depends  the  possibility  of 
prophylaxis. 

It  is  a  matter  of  no  importance  whether  such  prophylaxis 
takes  the  form  of  a  general  prophylaxis  under  the  care  of  the 
State  or  of  an  individual  prophylaxis  under  the  care  of  a 

74 


GENERAL  PROPHYLAXIS 

physician.  In  both  cases  it  will  be  necessary  in  the  first  place 
to  forbid  certain  individuals  from  marrying.  The  suggestion 
recently  made,  apparently  with  all  seriousness,  of  submitting 
all  degenerates  to  castration  cannot  for  the  present  be 
entertained.  Therefore  by  the  urgent  advice  of  the  family 
physician,  who  however  cannot  compel  its  adoption,  or  by 
laws  enacted  by  the  State,  we  should  be  justified  in 
forbidding  marriage  in  certain  cases,  cases  in  which  the 
hereditary  transmission  of  some  specific  tendency  to 
disease  is  certain  or  extremely  probable.  Which  are 
these?  One  need  but  put  the  question  in  practice  and 
difference  of  opinion  at  once  begins.  The  single  point 
about  which  all  are  agreed  is  that  those  who  have  any 
manifestations  of  syphilis  should  not  marry.  But  here  it 
is  not  a  question  of  true  heredity  but  of  intra-uterine 
infection,  and  this  must  obviously  be  prevented.  In 
tuberculosis  doubt  at  once  begins.  Intra-uterine  infection 
is  known,  but  it  is  so  rare  that  it  is  very  questionable 
whether  we  are  justified  in  forbidding  all  phthisical 
individuals  to  marry.  And  what  is  the  probability  of  the 
hereditary  transmission  of  the  tuberculous  predisposition  ? 
How  in  any  individual  case  is  it  possible  to  judge 
whether  such  transmission  is  possible,  probable,  or  even 
certain  ? 

And  now  with  regard  to  the  true  hereditary  diseases. 
There  is  no  doubt  that  there  are  apoplectic  families  and 
diabetic  families,  psychopathic  and  nervous  families ;  that 
is  families  in  which  the  special  disease  occurs  frequentl3^ 
But  what  is  meant  by  "  family  "  ?  "What  is  included  in 
the  term  ?  Those  only  who  bear  the  same  name  ?  This 
would  exclude  the  female  side  in  heredity.  The  science  of 
genealogy — a  special  science  having  its  own  methods — 
knows  this  and  tries  to  avoid  such  cardinal  mistakes.  The 
statements  in  many  medical  books  and  treatises  about 
inheritance  of  pathological  conditions  are  neither  more 
nor  less  than  a  collection  of  anecdotes  without  any  critical 
inquiry. 

Any  really  useful  prophylaxis  against  hereditary  disease 
will  only  be   possible  when    the    heredity   problem  in  its 

75 


THE  PREVENTION  OF  DISEASE 

relation  to  the  production  of  disease  has  been  to  some 
extent  cleared  up.  I  must  content  myself  with  these 
brief  remarks  to  show  that  there  is  a  scientific  basis  for 
general  prophylaxis. 

The  outcome  of  what  has  been  said  is  that  in  addition 
to  the  received  general  and  special  hygiene,  there  is  also  a 
general  and  special  prophylaxis,  which  deserves  to  be 
worked  out  scientifically  and  practically.  We  understand 
by  it  the  sum  of  all  purely  and  exclusively  medical 
knowledge  and  measures  whose  object  is  the  prevention 
of  disease.  These  are  in  part  general  and  in  part 
individual.  The  general  prophylactic  measures  are  those 
directed  against  agents  which  are  equally  injurious  for  and 
will  produce  disease  in  all  individuals  belonging  to  the 
group.  Individual  prophylaxis  presumes  the  existence  of 
some  constitutional  factor  which  will  cause  the  development 
of  disease  in  some  one  individual.  The  one  is  a  comple- 
ment to  the  other  and  passes  over  into  it  without  any  sharp 
line  of  demarcation.  The  more  general  the  measure,  the 
more  does  it  become  a  hygienic  work  in  which  not  only 
the  physician  but  also  the  engineer,  the  legislature  and 
the  educated  classes  take  part.  The  special  work  of  the 
ph^j'sician,  on  the  other  hand,  is  the  greater  the  more  it  is  a 
question  of  recognizing  and  removing  the  individual  factors 
of  disease,  that  is  to  say  predispositions  to  disease.  The 
last-named  factor  is  a  much  more  important  cause  of  the 
development  of  disease  than  is  usually  believed,  and  there 
is  no  danger  for  the  present  that  the  physician  will  have  to 
give  place  to  the  sanitarian.  On  the  contrary,  individual 
prophylaxis  is  one  of  the  most  important  clinical  tasks 
for  the  future. 


76 


The  Prevention  of  Internal  Diseases 


77 


The  Prevention  of  Internal   Diseases 

Owing  to  the  varying  nature  of  internal  diseases,  their 
preventive  treatment  differs  in  certain  particulars  from 
that  required  in  other  groups  of  disease.  In  surgery  and 
the  allied  branches  of  medicine,  external  injurious  influ- 
ences play  a  very  large  part  in  the  aetiology  of  disease, 
while  the  constitution  of  the  individual  himself  is  less  often 
a  prominent  factor.  In  such  circumstances  prophylaxis  is 
concerned  with  the  prevention  and  removal  of  these  inju- 
rious influences  which  are  external  to  the  individual,  rather 
than  with  the  individual  himself.  It  is  of  course  not 
altogether  a  matter  of  indifference  who  the  person  is  who 
slips  down  and  falls  upon  his  outstretched  hand,  or  who 
it  is  that  runs  an  infected  pin  into  his  fingers.  The  brittle 
radius  of  an  old  man  will  be  more  likely  to  break  than  the 
radius  of  a  young  man  ;  and  the  pin  will  only  pass  through 
the  thick  outer  horny  layer  of  the  skin  of  the  labourer's  hard 
hand,  while  it  will  penetrate  also  the  deeper  layers  of  a  more 
delicate  skin,  and  the  poison  will  be  deposited  there  and  set 
up  an  inflammatory  reaction.  In  such  cases  prophylaxis 
has  not  to  make  the  bones  more  capable  of  offering  resis- 
tance or  the  skin  thicker,  but  has  merely  to  direct  itself 
against  the  harmful  external  cause. 

It  is  otherwise  with  internal  medicine.  Here  we  can  only 
partially  succeed  in  removing  the  exciting  cause  of  the 
disease  or  in  discovering  specific  remedies.  Our  main 
concern  must  be  so  to  act  upon  the  functions  of  one 
or  more  of  the  bodily  organs  that  the  natural  powers  of 
resistance  of  the  body  against  the  exciting  cause  of  the 
disease  may  be  increased.  Consequently  in  our  preventive 
treatment  we  have  more  and  more  to  consider  the  indivi- 

79 


THE  PREVENTION  OF  DISEASE 

dual  himself  and  his  bodily  constitution  with  its  acquired 
and  its  inherited  peculiarities,  and  its  power  of  resisting 
injurious  influences.  As  a  rule  these  internal  diseases  arise 
because  there  is  a  disproportion  between  the  functional 
activity  of  an  organ  and  the  functional  requirements. 
Under  normal  conditions  of  the  body  these  two  correspond 
exactly ;  an  increase  in  the  functional  demands  is  accom- 
panied by  an  increase  in  functional  activity ;  a  decrease  in 
the  demands  by  a  decrease  in  activity.  The  normal  body 
is  able  to  adapt  itself,  in  the  sense  in  which  Darwin  used 
the  term,  not  only  to  its  general  surroundings — the  climatic 
conditions,  the  food  and  the  other  conditions  of  life — but  also 
to  any  special  demands  which  are  brought  to  bear  upon  it. 
These  influences  may  be  mechanical  in  their  nature,  such 
as  powerful  muscular  efforts  which  it  meets  by  increased 
metabolism,  increased  circulation  and  deeper  respiration ;  or 
they  may  be  sudden  changes  of  temperature  to  which  the 
skin  is  exposed  and  which  are  promptly  compensated  for  by 
contraction  or  dilatation  of  the  cutaneous  vessels ;  or  again 
they  may  be  bacteria  which  have  got  into  the  respiratory 
passages  or  into  the  digestive  tract,  and  are  overcome  by 
the  action  of  the  epithelium  or  are  expelled  from  the  body 
by  a  violent  coughing  effort  in  the  one  case  or  by  increased 
peristalsis  in  the  other. 

There  is  however  a  natural  limit  to  the  demands  which 
may  be  made  upon  the  organism,  and  when  this  limit  is 
exceeded  the  organism  suffers.  The  body,  or  generally 
that  part  of  the  body  which  is  attacked,  then  undergoes 
a  change  which  leads  to  further  changes — functional  or 
anatomical.  These  changes  are  accompanied  by  a  tempo- 
rary or  permanent  weakening  of  the  body,  and  the  condi- 
tion is  then  called  morbid.  This  process  of  "pathological 
reaction  "  is  not  essentially  different  from  the  above  men- 
tioned process  of  "physiological  reaction."  Often  the  one 
passes  imperceptibly  into  the  other,  so  that  the  difference 
is  merely  one  of  degree  ;  but  the  results  brought  about 
by  the  two  processes  are  very  different,  the  physiological 
reaction  is  quickly  over,  the  pathological  reaction  lasts 
more  or  less  long  and  always  weakens  the  organism. 

80 


THE  PREVENTION   OF  INTERNAL  DISEASES 

The  exciting  causes,  the  stimuli,  are  essentially  the  same 
in  both  processes  ;  different  organisms,  and  even  the  same 
organism  at  different  times,  will  react  differently  to  the 
same  stimulus.  A  cold  current  of  air  in  one  case  will  call 
forth  adequate  functional  activity  of  the  cutaneous  vessels, 
and  the  effect  of  the  cold  air  upon  the  body  will  be  exactly 
balanced  :  this  is  physiological  reaction.  While  in  another 
case  the  cold  air  produces  hyperaemia  and  then  bronchitis 
or  some  other  disease.  This  is  pathological  reaction.  A 
dish  of  "  Sauerkraut "  will  cause  a  violent  attack  of  gastro- 
intestinal catarrh  in  one  man,  while  another  man  will 
thoroughly  enjoy  the  same  dish  !  Thus  the  various  known 
exciting  causes  of  disease — such  as  cold  and  other  atmo- 
spheric conditions,  getting  wet  through,  excess  in  eating  and 
drinking,  strains,  poisons,  and  the  entry  of  bacteria  into  the 
body — do  not  always  cause  disease,  but  only  when  they  • 
chance  to  reach  a  body  which  is  prepared  to  react  patho- 
logically. The  kind  of  reaction  by  which  the  body  responds 
to  any  stimulus  depends  upon  peculiarities  for  which  we 
are  seldom  able  to  find  an  anatomical  explanation,  and 
they  are  said  to  rest  upon  the  general  constitution.  A 
good  constitution  would  be  one  which  could  adapt  itself  to 
all  influences  of  life,  to  which  it  would  always  "  react 
physiologically."  In  truth  no  such  "  good  constitution  " 
exists,  and  we  are  content  to  describe  a  man  as  possessing 
a  good  or  healthy  constitution  when  it  suffers  no  ill  effect 
from  the  ordinary  stimuli  of  daily  life.  The  standard  for 
health  is  not  the  same  for  all  men :  one  man  can  do  hard 
physical  labour  with  ease,  thanks  to  his  strong  muscular 
system,  but  a  sudden  change  in  the  weather  or  a  chill 
will  often  give  him  a  cold ;  and  conversely,  another  man  has 
little  power  of  doing  hard  physical  work  but  never  takes 
cold.  The  body  is  not  capable  of  meeting  all  demands  upon 
it  equally.  So  long  as  there  is  nothing  obviously  wrong 
in  any  organism  and  it  is  able  to  do  its  ordinary  work 
with  comfort,  it  may  be  considered  healthy. 

A  weak  constitution  does  not  necessarily  give  rise  to 
disease  whenever  it  is  exposed  to  injurious  conditions. 
One  man  with  a  weak  constitution  may  continue  in  good 

81  G 


THE  PREVENTION  OF  DISEASE 

health  for  many  years  and  may  not  suffer  from  illness 
brought  on  by  his  constitution  until  middle  life  ;  we  need 
but  mention  gout  and  diabetes  as  examples.  In  other  cases 
again  various  symptoms  may  appear  early  though  it  can- 
not be  said  that  any  disease  is  present ;  medically  these 
symptoms  indicate  a  definite  kind  of  constitution,  and  the 
disease  appears  later  when  called  forth  by  some  exciting 
cause.  These  symptoms  characteristic  of  a  certain  consti- 
tution may  however  again  disappear  and  no  disease  be  de- 
veloped ;  the  constitution  of  an  individual  is  not  fixed  and  in- 
capable of  modification,  but  may  be  altered  by  the  different 
conditions  of  daily  life.  The  constitution  depends,  first  upon 
inherited  predisposition,  and  next  upon  the  acquired  pecu- 
liarities of  the  organism.  An  originally  strong  constitution 
may  under  unfavourable  conditions  become  a  bad  constitu- 
tion, and  conversely  a  weak  constitution  may  be  strengthened 
by  favourable  circumstances  and  the  disease  peculiar  to  that 
weak  constitution  never  be  developed. 

In  these  cases  the  objects  of  prophylactic  treatment  are 
self-evident.  Firstly  our  duty  is  to  prevent  or  remove  all 
injurious  external  conditions  which  experience  has  shown 
will  contribute  to  the  development  of  disease  ;  secondly 
our  duty  is  to  strengthen  or  improve  the  faulty  constitution 
and  thus  remove  the  predisposition  to  disease.  It  is  essen- 
tial that  we  should  recognize  early  the  existence  of  a 
predisposition,  and  this  is  made  possible  by — 

Firstly :  a  knowledge  of  the  hereditary  tendency  of 
certain  diseases ; 

Secondly :  a  knowledge  of  the  definite  signs  and  early 
manifestations  peculiar  to  a  certain  constitution,  particularly 
during  the  years  of  growth  ;  and 

Thirdly  :  a  knowledge  of  the  changes  in  the  constitution 
and  functions  of  the  organism  which  often  follow  an  illness, 
which  appear  at  certain  epochs  of  life  and  which  accompany 
a  complete  change  in  the  conditions  of  existence. 

The  prophylactic  measures  to  improve  the  constitution 
cannot  be  enumerated  once  for  all,  because  they  differ  accord- 
ing to  the  organ  or  symptom  upon  the  defective  nature  of 
which  the  faulty  constitution  rests.      All  diseases  indeed 

82 


THE  PREVENTION  OF  INTERNAL  DISEASES 

are  in  a  way  constitutional.  Whether  the  disease  be  one 
affecting  the  heart,  the  lungs,  or  the  processes  of  metabol- 
ism, or  whether  it  be  a  so-called  infective  disease,  there  is 
a  certain  predisposition  to  it  in  the  particular  individual, 
and  when  some  external  injurious  factor  is  added  the 
disease  developes.  The  differences  between  the  various 
diseases  depend  upon  the  part  of  the  body  affected,  the 
constitution  and  the  external  harmful  influences  which 
have  combined  to  produce  the  disease.  In  most  so-called 
infective  diseases  the  last  named  factor — infection — pre- 
dominates, and  the  constitution  is  of  comparatively  slight 
importance :  for  example,  malignant  anthrax  is  a  disease 
which  probably  always  developes  when  the  bacillus 
anthracis  enters  the  body.  The  cholera  vibrio  however  is 
occasionally  found  in  the  evacuations  of  healthy  people.  In 
tuberculosis  constitutional  predisposition  is  the  most  im- 
portant factor. 

And  further,  the  course  run  by  these  diseases  is  not  the 
same  in  every  individual.  Not  only  may  the  final  conse- 
quences of  any  disease  be  different,  but  their  whole  clinical 
course  and  sometimes  even  their  pathological  and 
anatomical  forms  may  be  different  in  different  individuals. 
This  is  daily  seen  in  tuberculosis  by  every  doctor.  In 
epidemics  too,  where  there  cannot  be  very  great  differences 
in  the  degree  of  virulence  of  the  poison,  we  see  neverthe- 
less very  great  differences  in  the  severity  of  the  attack 
depending  upon  the  individual  who  is  affected,  that  is 
upon  his  constitution.  The  same  is  also  true  for  all  other 
diseases  :  whatever  be  the  external  exciting  cause,  the  con- 
stitution nevertheless  determines  the  course  which  the 
disease  runs. 

Although  it  is  now  evident  that  almost  all  internal 
diseases  are  to  a  certain  extent  constitutional,  yet  in 
medicine  we  have  long  been  accustomed  to  give  the  name 
of  "  constitutional  disease  "  to  a  certain  number  of  diseases, 
mostly  diseases  of  the  blood,  such  as  anaemia,  chlorosis, 
leukaemia,  haemophilia  and  scurvy.  We  generally  also 
include  disorders  of  metabolism,  such  as  gout,  diabetes, 
obesity,    rickets  and    scrofula.       These  diseases   do  indeed 

83 


THE  PEEVENTION   OF  DISEASE 

possess  certain  characteristics  which  distinguish  them  from 
other  groups  of  diseases.  They  run  a  chronic  course  and 
from  their  very  beginning  affect  the  whole  organism,  and 
though  some  external  condition  may  help  to  cause  the 
disease,  yet  any  very  obvious  and  tangible  exciting  cause 
is  wanting.  The  constitution  is  essentially  the  determin- 
ing cause,  and  the  peculiarity  of  the  constitution  is  generally 
inherited.  Nevertheless  no  really  fundamental  difference 
separates  these  diseases  from  the  rest,  and  there  are  inter- 
mediate forms  which  connect  these  two  groups.  "We  need 
only  mention  tuberculosis  as  an  example,  for  some  writers 
describe  it  under  "the  infectious  diseases,"  others  under 
"  constitutional  affections,"  and  others  under  diseases  of  the 
lungs.  From  what  has  been  said  above  about  constitution 
it  is  obvious  that  any  classification  of  diseases  into  groups 
must  be  artificial,  but  it  is  convenient  for  the  study  of 
diseases. 

Ebstein  groups  the  diseases  we  have  mentioned  under 
"  diseases  of  the  protoplasm,"  and  Immermann  under 
"  general  disorders  of  nutrition."  This  would  compel  us 
to  include  under  the  disorders  of  nutrition  such  a  disease 
as  hereditary  and  constitutional  syphilis,  and  those  diseases 
in  which  there  is  a  chronic  state  of  malnutrition  as  in  the 
cachexias  of  cancer  and  malaria.  It  seems  best  therefore 
to  consider  the  prevention  of  the  diseases  of  the  blood  and 
of  the  disorders  of  metabolism  in  the  narrower  sense, 
separately  from  the  rest. 


84 


The  Prevention  of  Diseases  of  the  Blood 


BY 

DR.   EOSEN 


86 


The  Prevention  of  Diseases  of  the  Blood 

Conditions  of  anaemia  are  so  numerous  and  aetiologically  ' 

so  different  that  they  cannot  be  prevented  by  any  single 
method  of  prophylactic  treatment :  for  instance  anaemia 
may  arise  suddenly  from  severe  haemorrhage,  or  it  may  be 
a  sequela  of  some  severe  febrile  disease,  or  it  may  be  chronic 
and  secondary  to  some  morbid  condition ;  for  all  these 
varieties  the  prophylactic  treatment  cannot  be  the  same. 
The  ordinary  simple  anaemia  which  is  so  common  and  gives 
rise  to  no  symptoms  in  itself,  can  scarcely  be  called  a 
disease,  but  it  becomes  a  disease  when  diminished  functional 
activity  and  other  general  disturbances  are  associated  with 
the  anaemia.  It  is  met  with  mostly  in  women  during  the 
second  decade  of  life,  and  aetiologically  has  much  in 
common  with  chlorosis,  and  the  prophylactic  treatment  of 
the  two  is  essentially  the  same.  Premonitory  signs  of  this 
disease  often  appear  during  childhood ;  these  children  are 
pale,  their  muscles  are  flabby  and  their  appetite  bad,  and 
they  take  every  possible  ailment,  and  especially  they  readily 
catch  cold  and  are  a  great  trouble  to  the  family  physician. 
Their  "  delicate  health  "  is  partly  the  outcome  of  heredity, 
partly  the  result  of  improper  bringing-up.  Moreover 
during  puberty  young  girls  in  civilized  countries  are  so 
much  troubled  with  anaemia  and  chlorosis,  that  prophy- 
lactic measures  are  suitable  for  nearly  all  of  them. 

The  old  medical  textbooks  recommend  plenty  of  meat, 
not  only  as  a  valuable  remedy  in  anaemia  and  chlorosis  but 
also  as  a  preventive.  But  our  views  about  the  supreme 
value  of  a  diet  consisting  largely  of  meat  or  of  nitrogenous 
food  have  been  completely  changed  by  the  great  advances 

87 


THE  PREVENTION  OE  DISEASE 

made  during  tte  last  decade  in  the  physiology  of  food,  by 
Voit,  Pettenkofer  and  Eubner ;  moreover  anaemia  and 
chlorosis  are  not  primarily  disorders  of  nutrition,  but  primary 
disorders  of  the  formation  of  blood  which  are  not  dependent 
upon  the  nutrition  of  the  body.  Naturally,  insufficient 
nourishing  food  for  any  length  of  time  will  reduce  the 
activity  of  the  organs  which  form  blood,  as  it  does  in  the 
case  of  all  other  organs.  Conversely  when  the  circulation 
is  defective  the  organs  of  absorption  finally  suffer  too.  In 
the  prophylactic  treatment  of  anaemia  and  chlorosis  there 
is  no  indication  to  depart  from  ordinary  diet.  The  diet 
should  include  the  three  principal  kinds  of  food  in  the 
proportions  which  the  principles  of  physiology  have  shown 
to  be  necessary.  Cereals  should  predominate  in  quantity, 
and  half  a  pound  of  meat  daily  on  an  average  is  sufficient. 
The  diet  of  women  who  work  in  the  factories  of  large 
towns  is  generally  insufficient :  it  does  not  contain  enough 
nitrogenous  food,  because  the  foods  rich  in  nitrogen,  such 
as  meat  and  eggs,  are  too  expensive  for  them.  It  may  be 
well  here,  in  connexion  with  the  diet  of  poor  people,  to 
point  out  that  the  increase  and  extension  of  sea  fisheries 
have  made  fish  very  cheap,  whether  fresh,  smoked  or  dried, 
as  cod,  haddock  and  sturgeon.  Recent  attempts  to  make  arti- 
ficial nitrogenous  preparations,  such  as  "  tropon"  by  Finkler, 
deserve  attention,  but  for  the  present  need  not  be  considered 
as  entering  into  the  diet  of  the  masses  ;  moreover  tropon 
is  readily  deposited  in  fine  powder  from  its  solutions,  and 
is  not  enjoyed  when  taken  for  any  length  of  time. 

In  addition  to  a  suitable  diet  the  prophylactic  treatment 
of  anaemia  and  chlorosis  includes  an  hygienic  mode  of  life 
during  growing  youth.  It  is  one  of  the  difficult  duties  of 
the  family  physician  to  arrange  this.  This  subject  however 
belongs  rather  to  general  hygiene  and  cannot  be  described 
here,  though  a  few  of  the  most  important  points  may  be 
named.  As  to  games  :  it  is  good  that  girls  nowadays  play 
more  at  games  and  thereby  get  out  more  into  the  fresh  air, 
use  their  muscles  and  increase  their  metabolism.  But  we 
must  caution  them  against  overdoing  it,  because  over- 
fatigue and  over-exertion  lead  to  anaemia  and   chlorosis. 

88 


THE  PREVENTION  OF  DISEASES  OF  THE  BLOOD 

Grirls  who  go  out  to  service  "where  the  work  is  hard  often  get 
chlorosis  though  the  surrounding  external  conditions  are 
good  and  healthy,  and  the  chlorosis  improves  directly  the 
girls  leave  service  for  a  few  weeks'  rest.  Girls  should  there- 
fore not  be  sent  out  to  service  too  young,  not  before  they  are 
seventeen  or  eighteen  years  of  age,  even  though  they  may  look 
strong  and  well-developed.  Among  factory  girls  and  shop  girls 
in  large  towns,  who  so  very  often  suffer  from  anaemia  and 
chlorosis,  generally  combined  with  nervous  debility  and 
other  secondary  ailments,  over-strain  by  working  beyond 
their  powers  is  a  very  important  causative  factor.  They 
leave  their  home,  already  feeling  weak  in  muscle  and  nerve, 
are  occupied  the  whole  day  with  their  work,  the  monotonous 
nature  of  which  is  in  itself  tiring,  and  in  addition  have 
often  to  walk  a  long  distance  to  get  from  their  home  on  the 
outskirts  of  the  town  to  their  work  near  the  centre. 
Experience  shows  that  very  few  of  them  ride  to  their  work  : 
they  walk  there  and  back  in  order  to  save  the  fares. 
Imagine  a  weakly  girl  who  gets  up  between  five  and  six 
o'clock  in  the  morning,  then  has  an  hour  or  perhaps  more 
to  walk  to  her  work,  works  there  till  evening  with  a  short 
interval  at  midday,  standing  or  walking  about  much,  she 
has  an  hour's  walk  or  more  home  in  the  evening  to  her 
supper  when  she  is  tired  and  done  up ;  and  this  meal  is  the 
principal  meal  in  the  day.  At  midday  these  girls  generally 
eat  in  the  factory  a  slice  of  bread  and  butter  only  which 
they  have  brought  with  them  from  home.  These  girls  on 
reaching  home  at  night  are  often  so  depressed  that  they 
have  no  appetite  for  supper  and  go  to  bed  overtired  and 
without  having  had  sufficient  food.  And  then  anaemia 
and  chlorosis  with  nervous  debility  and  other  diseases  do  not 
fail  to  appear.  Medical  treatment  can  often  do  much  for 
these  girls  by  ordering  them  to  ride  home  at  night :  in  a 
short  time  one  generally  hears  that  they  have  a  better 
appetite  in  the  evening  and  feel  refreshed  and  sleep  better 
at  night.  It  is  therefore  most  essential  that  the  physician 
should  find  out  exactly  how  much  work  each  girl  does.  In 
many  cases  he  will  consider  it  necessary  to  curtail  the  work, 
not   by  reducing  the  work  actually  done  at  the  factory, 

89 


THE  PREVENTION  OF  DISEASE 

but   by   cutting  off  other   avoidable   forms  of   work    and 
exercise. 

The   conditions  are   again  different  with  people   whose 
occupation  is  almost  entirely  mental  and  who  are  obliged 
to  sit  in  their  rooms  all  the  day.     In  this  connection  we 
must  consider  schools,  especially  high  schools,  whose  methods 
of  education  we  are  endeavouring  at  the  present  time  to 
reform.     We  need  only  mention  here  the  great  questions 
of    overstrain  and  the  substitution  of  natural  science  for 
some   of   the  other  studies  and   the  use  of  object  lessons, 
Grymnastic    exercises   are   receiving   greater   attention    in 
schools,  but  they  are  sometimes  injudiciously  given  in  the 
early  hours  of  the  day  instead  of  at  the  close  of  the  morn- 
ing or  still  better  during  the  afternoon.     When  given  in 
the  early  hours  the  tiredness  left  after  gymnastic  exercises 
prevents  proper  attention  being  given  to  the  lessons  which 
follow.       Harmonious  development  of   body   and   mind  is 
wanted  for  the  young ;  unequal  development  injures  both 
body  and  mind,  checks  the  natural  cheerfulness  of  youth 
and    makes    them    pale-cheeked    and    peevish   pessimists. 
Unfortunately  the  parents  often  from  lack  of  judgment  and 
from  vanity  spur  on    their  weak    children  to  exclusively 
mental  work,  that  they  may  take  the  first  places  at  school 
and  bring  home  brilliant  school  reports,  while  their  bodily 
development  remains  far  behind  the  average  for  their  age. 
To   interfere  in  these  cases  will  be  one  of  the  important 
duties  of   school  physicians ;    long  lasting  severe  anaemic 
conditions   often  enough  result   from  such   forced   mental 
development  and  neglect  of  the  body,  and  it  is  therefore 
well  to  take  these  children  away  from  school  for  half-a-year, 
utilizing  this  period  to    rest   the    brain  entirely  and    to 
strengthen   the   weak    body    by    suitable    diet,    moderate 
exercise  in  the  fresh  air,  cool  baths  and  similar  measures. 

In  adults  too,  the  severe  mental  work  of  professional 
life  and  of  other  callings  which  are  sedentary  often  leads 
to  anaemia  and  its  consequences,  and  what  has  been  recom- 
mended for  school  children  is  required  for  these  cases  also. 
The  patient  should  follow  hygienic  rules  and  get  sufficient 
bodily   exercise   out   of    doors  by  sports  and  by  walking. 

90 


THE   PREVENTION   OE   DISEASES   OF   THE   BLOOD 

Unfortunately  ball  games  in  the  open  air  for  adults  are 
not  yet  the  custom  in  Germany  as  they  are  in  England  ; 
and  for  the  sake  of  our  health  it  is  much  to  be  regretted 
that  these  games  are  considered  undignified  for  the  adult. 
The  appropriate  interchange  between  rest  and  active  move- 
ment in  these  games,  and  the  enjoyment  they  give  are 
excellent  both  for  body  and  mind. 

The  connection  between  sexual  processes  and  anaemia  and 
chlorosis  needs  mention  in  relation  to  prophylaxis,  especi- 
ally in  the  female  sex,  in  whom  tliis  connection  is  so  often 
seen,  chiefly  at  the  time  when  the  catamenia  first  appear. 
The  essential  nature  of  this  connection  which  we  meet  with 
daily  in  medical  practice  is  as  little  understood  as  is  that 
of  chlorosis  itself.  With  the  changes  in  the  entire  circula- 
tory system  which  are  ushered  in  by  the  commencement 
of  menstruation  a  tendency  to  chlorosis  appears,  and  the 
tendency  is  greater  when  menstruation  does  not  develop 
quite  normally.  The  various  anomalies  of  menstruation, 
especially  menorrhagia  and  dysmenorrhoea  which  favour 
the  onset  of  chlorosis  belong  to  gynaecology,  and  such  cases 
of  chlorosis  will  be  prevented  by  removing  these  menstrual 
anomalies.  Even  normal  menstruation  during  the  years 
of  growth  may  favour  an  attack  of  chlorosis,  and  it  is  an 
important  duty  to  secure  suitable  conditions  for  young  girls 
during  the  catamenia  with  avoidance  of  all  mental  and 
physical  over-exertion — very  delicate  girls  require  com- 
plete rest  for  several  days.  There  should  be  an  adequate 
diet  and  regular  evacuation  of  the  bowels.  Further  details 
are  given  in  the  section  on  the  Prevention  of  the  Diseases 
of  Women.  Medical  experience  shows  that  the  early 
appearance  of  puberty  favours  the  development  of  chlorosis, 
but  we  have  no  definite  statistics  about  this.  There  are 
differences  in  the  age  at  which  the  catamenia  begin  which 
depend  upon  climate  and  race :  we  are  not  referring  to 
those  cases  but  to  the  early  appearance  of  the  catamenia 
which  depends  upon  the  mode  of  life.  According  to 
Krieger  the  average  age  at  which  menstruation  begins  is 
14"69  years  among  the  higher  classes  and  16  years  among 
the   lower  classes   of   society.     "  Luxury  and  good  living 

91 


THE  PEEVENTION  OF  DISEASE 

tend  to  cause  the  early  appearance  of  menstruation,  and  so 
too  do  early  over-excitement  of  the  nervous  system  by 
theatre-going,  late  parties  and  exciting  literature." 

Menstruation  appears  earlier  in  girls  who  live  in  town 
than  in  country  girls  whose  frugal  regular  habits  of  life 
and  hard  work  delay  puberty.  The  prophylactic  measures 
required  to  prevent  precocity  are  those  so  often  emphasized  by 
doctors  and  teachers,  namely — Simplicity  in  the  whole  mode 
of  life  and  the  preservation  of  childlike  feelings  ;  a  regular 
plan  for  the  day's  work  ;  early  rising  and  early  going  to 
bed  ;  supervision  of  her  friends  and  of  her  reading  ;  harden- 
ing the  body  by  cold  baths,  swimming,  gymnastics,  games 
and  training  in  real  work.  All  these  are  factors  which 
the  family  physician  may  use  for  the  prevention  of  chlorosis 
in  young  girls.  These  measures  at  the  same  time  tend  to 
prevent  the  development  of  habits  of  masturbation,  the 
prevalence  of  which  among  boys  and  also  among  girls  has 
often  been  pointed  out,  and  which  not  seldom  favour  the 
development  of  anaemia  and  chlorosis.  In  many  books 
written  on  this  subject  we  find  the  statement  repeatedly 
made  but  not  proved  that  so-called  ''  boarding  schools  "  to 
which  young  girls  in  the  higher  ranks  of  life  are  generally 
sent  for  completion  of  their  education,  are  often  hotbeds 
for  all  kinds  of  pernicious  sexual  habits  ;  as  if  these  did  not 
occur  often  among  girls  not  sent  to  boarding  schools. 

Marriage  has  been  recommended  as  a  preventive  as  well 
as  a  cure  for  chlorosis,  on  the  supposition  that  the  complete 
establishment  of  the  sexual  functions  counteracts  chlorosis. 
But  chlorosis  in  married  women  is  not  rare  ;  we  need 
merely  point  out  that  affections  of  the  heart,  and  a  ten- 
dency to  haemorrhage  and  nervous  diseases  often  appear 
as  sequelae  of  chlorosis,  in  order  to  understand  the  great 
dangers  which  threaten  such  a  chlorotic  woman  who  has 
married  and  has  become  pregnant.  Indeed  pregnancy  and 
labour  are  often  important  factors  in  the  production  of 
anaemia.  It  is  therefore  not  right  to  recommend  marriage 
as  a  prophylactic  or  even  as  a  therapeutic  measure  against 
chlorosis.  On  the  contrary,  as  a  therapeutic  measure  we 
ought  rather  to  discountenance  marriage,  in  order  that  the 

92 


THE  PREVENTION  OF  DISEASES   OF  THE  BLOOD 

complications  of  chlorosis  may  be  prevented,  especially  the 
affections  of  the  heart  and  vascular  system  which  preg- 
nancy tends  to  produce.  Consent  to  marriage  should  not 
be  given  till  the  chlorosis  is  completely  cured.  Similarly 
marriage  as  a  general  prophylactic  must  not  be  recom- 
mended for  delicate  weakly  girls  predisposed  to  chlorosis, 
particularly  if  they  have  already  had  chlorosis  or  if  there  is 
a  family  tendency  to  it.  Early  marriage  should  then  be 
discountenanced,  seeing  that  it  brings  with  it  the  prob- 
ability of  pregnancy.  There  are  however  cases  in  which 
the  health  of  the  girl  is  injured  and  she  becomes  anaemic 
and  chlorotic — not  through  any  congenital  morbid  tendency 
but  through  an  unsuitable  mode  of  life  through  the  want 
of  sufficient  active  occupation,  through  many  kinds  of 
fashionable  follies  which  are  so  common  among  the 
higher  ranks  of  life.  In  these  cases  marriage  may  be  an 
aid  to  health,  chiefly  because  these  young  ladies  have  then 
the  responsible  management  of  their  households  with  serious 
duties  and  regular  occupation,  and  their  life  becomes  wider 
and  is  led  into  quiet  and  regular  ways.  We  then  see 
many  a  young  woman  grow  strong  who  was  pale  and  thin 
as  a  girl ;  others  however  get  only  worse.  Therefore  the 
mother's  question  whether  her  daughter  should  marry  must 
be  answered  with  great  caution  and  only  after  considering 
carefully  all  the  circumstances  of  the  case. 

Another  disease  of  the  blood  which  requires  special  pro- 
phylactic treatment  is  haemophilia,  a  somewhat  rare 
but  extremely  dangerous  malady.  It  is  not  exactly  a 
disease  but  rather  an  hereditary  constitutional  anomaly. 
It  is  markedly  hereditary  and  prophylaxis  is  concerned  with 
the  question  of  marriage  with  members  of  such  families. 
According  to  Immermann's  well  known  researches  and 
statistics  it  is  not  necessary  to  forbid  marriage  to  all  the 
relatives  of  such  families  without  exception  ;  the  following 
rules  are  sufficient  for  guidance — 

Firstly  :  men  belonging  to  families  of  bleeders  and  who 
are  themselves  bleeders  generally  beget  healthy  children 
who  are  not  bleeders  if  the  mother  does  not  come  from  a 
family  of   bleeders.     On  the  other  hand  children  born  of 

93 


THE  PREVENTION   OF  DISEASE 

mothers  who  are  haemophilic  are  invariably  bleeders 
also. 

Secondly  :  men  belonging  to  a  family  of  bleeders  who 
are  not  themselves  haemophilic  will  practically  never  have 
children  who  are  bleeders  if  they  marry  a  woman  not 
coming  from  a  family  of  bleeders. 

Thirdly :  among  the  children  of  women  who  are  not 
themselves  bleeders,  but  who  are  descended  from  families 
of  bleeders,  there  are  almost  always  children  who  sufifer 
from  well  marked  haemophilia. 

This  shows,  though  we  do  not  know  the  explanation  of 
it,  that  in  haemophilia  the  tendency  is  almost  entirely 
transmitted  through  the  mother,  and  medical  consent  to 
marriage  should  not  be  given  to  any  woman  descended  from 
a  family  of  bleeders,  whether  she  herself  be  a  bleeder  or 
not.  Generally  the  women  themselves  are  not  bleeders. 
Among  650  cases  of  developed  haemophilia  recorded  in 
medical  literature,  Immermann  found  that  women  formed 
only  eight  per  cent,  of  the  cases  and  men  ninety-two  per 
cent.  The  male  members  of  families  of  bleeders  may  marry 
without  much  risk  if  they  are  not  themselves  bleeders ;  but 
if  they  are  themselves  bleeders  Immermann  recommends 
that  the  history  of  the  family  should  be  inquired  into  before 
an  opinion  is  given.  If  the  inquiry  shows  that  haemophilia 
has  repeatedly  descended  from  father  to  son  marriage  should 
not  be  advised,  if  on  the  other  hand  the  tendency  to 
haemophilia  appears  only  on  the  female  side  and  not  at  all 
on  the  male  side,  then  there  is  no  reason  whatever,  from  a 
medical  point  of  view,  to  urge  against  the  marriage  of  the 
man  who  is  a  bleeder. 

When  haemophilia  is  present  or  there  is  a  probability  of 
its  appearance  on  account  of  heredity'-,  prophylaxis  is  con- 
cerned with  avoiding  every  possible  cause  of  injury. 
Grrandidier  found  that  the  first  haemorrhage  appeared  during 
the  first  two  years  of  life  in  69-5  per  cent,  of  the  cases  : 
children  should  therefore  be  specially  guarded  during  the 
first  years  of  life  and  shielded  from  injuries,  and  later 
gymnastics  must  be  strictly  forbidden.  Operative  pro- 
cedures, even  the    simplest  and  most  trivial  ones,   should 

94 


THE  PREVENTION   OF  DISEASES   OF   THE  BLOOD 

never  be  undertaken  except  when  urgently  needed.  The 
ritual  circumcision  of  Jewish  boys  in  families  of  bleeders 
should  be  omitted,  for  G-randidier's  statistics  show  eight 
cases  of  death  from  haemorrhage  after  circumcision. 
Immermann  considers  the  operation  of  vaccination  free 
from  danger  if  very  carefully  performed.  Extraction  of  teeth 
is  an  extremely  dangerous  operation  in  bleeders  ;  Grandidier 
collected  thirteen  deaths  and  forty  extremely  serious 
cases  of  haemorrhage  which  did  not  however  prove  fatal. 
Unfortunately  neuralgia  of  the  dental  branches  of  the 
trigeminal  nerve  appears  to  be  very  common  in  bleeders, 
and  they  are  therefore  induced  to  have  their  teeth  extracted 
in  spite  of  all  warnings. 

A  means  for  checking  haemorrhage  in  haemophilia 
has  lately  been  again  brought  forward  and  is  worthy  of 
notice.  Lanceraux  in  France  recommended  the  hypodermic 
injection  of  a  one  per  cent,  gelatine  solution  to  check  severe 
haemorrhages ;  the  coagulability  of  the  blood  is  said  to  be 
increased  thereby  and  the  tendency  to  formation  of  thrombi 
in  the  bleeding  vessels  promoted.  Favourable  accounts 
have  recently  been  received  from  different  quarters,  from 
French,  Russian  and  German  writers,  and  quite  recently 
from  Curschmann,  about  the  effect  of  these  injections  of 
gelatine  in  various  kinds  of  haemorrhage,  especially 
haematemesis  and  haemoptysis.  Generally  200  grams  of  a 
sterile  one  per  cent,  solution  of  gelatine  were  injected  on 
several  consecutive  days.  Sometimes  stronger  solutions,  ten 
per  cent.,  were  administered  by  the  mouth  or  by  the  rectum. 
Theoretically  therefore  it  might  be  advisable  before  under- 
taking any  operation  upon  a  bleeder  to  inject  a  solution 
of  gelatine  and  thus  possibly  artificially  to  increase  the 
coagulability  of  the  blood.  So  far  as  we  know  this  has  not 
yet  been  practically  attempted  but  we  recommend  it  as 
rational  in  such  cases. 

In  old  medical  works  scurvy  and  its  prevention  occupy 
a  large  space.  Nowadays  scurvy  among  landsmen  is  so 
rare  that  most  doctors  never  see  a  case.  The  general  im- 
provements in  the  conditions  of  life,  in  the  dwellings,  in  the 
diet,  and  in  the  care  of  the  body  have  caused  the  disease 

96 


THE  PREVENTION  OF  DISEASE 

almost  to  disappear,  thougli  formerly  it  was  epidemic  iii 
prisons,  barracks  and  infirmaries.  Scurvy  still  often  occurs 
on  ships  in  the  arctic  regions,  sometimes  caused  by  unfavour- 
able climatic  conditions,  sometimes  through  the  unsuitable 
nature  of  the  food,  for  the  men  are  compelled  from  lack  of 
vegetables  and  especially  of  fresh  vegetables  for  long  periods 
to  eat  chiefly  meat,  and  especially  salt  meat  or  dried  meat 
and  fish.  When  it  became  known  that  the  absence  of 
potassium  compounds  which  we  generally  get  from  the 
plants  we  eat  was  an  important  reason  of  the  unsuitability 
of  such  a  diet,  it  was  recommended  in  order  to  prevent 
scurvy  that  sailors  should  take  fresh  vegetables,  potatoes 
or  fruit  so  far  as  possible,  or  failing  this  preserved 
vegetables  or  certain  preserved  fruits  which  keep  for  a  long 
time,  to  supply  the  want  of  potassium  compounds.  Lime- 
juice  has  since  proved  especially  valuable  in  this  con- 
nection. 


96 


The   Prevention  of  the   Diseases  of 
Metabolism 


BY 

DR.   ROSEN 


97 


The   Prevention   of  the   Diseases   of 
MetaboHsm 


In  earlier  times  propliylactic  treatment  in  the  narrower 
sense,  to  maintain  normal  metabolism  of  the  body,  was 
generally  carried  out  though  without  any  medical  prescrip- 
tions. The  "Spring-cure"  was  much  valued ;  it  consisted 
chiefly  in  taking  aperients  regularly  for  several  weeks  in  the 
spring.  The  object  was  to  expel  from  the  body  the  effete 
material  which  had  gathered  during  the  winter  and  so  stimu- 
late the  bodily  functions  to  renewed  activity.  Regular  treat- 
ment by  sweating  or  by  water  drinking  had  the  same  object, 
namely  to  expel  impurities  by  profuse  perspirations  or 
copious  diuresis.  Venesection  too  was  periodically  prac- 
tised and  often  to  such  an  extent  as  seriously  to  injure  the 
patient.  These  general  "  cures  "  are  no  longer  in  vogue  ;  a 
life  lived  according  to  the  principles  of  hygiene  is  a  general 
prophylactic  against  diseases  of  metabolism,  and  only  a 
certain  number  of  individuals  need  any  other  special  pre- 
ventive rules.  Diseases  of  metabolism,  such  as  diabetes, 
gout  and  the  uric  acid  diathesis,  as  well  as  obesity,  tend  to 
be  inherited.  External  injurious  conditions,  accidents, 
mental  influences,  diseases  and  excesses  may  help  to  develop 
the  disorders,  but  these  are  generally  only  the  exciting- 
cause,  while  the  real  cause  is  to  be  found  in  the  constitu- 
tion of  the  individual  and  in  the  peculiar  functional  tenden- 
cies of  his  cells.  In  this  way  the  hereditary  nature  of 
these   disorders   is   explained,    and    prophylactic    measures 

99 


THE   PREVENTION   OF  DISEASE 

should  be  commenced  earlj^  in  those  whose  ancestors  have 
suffered  from  them.  The  similarity  of  these  diseases  of 
metabolism  is  shown  by  the  fact  that  they  may  alternate 
in  different  generations,  and  it  follows  that  certain  general 
prophylactic  measures  are  indicated  for  all  who  are  heredit- 
arily predisposed.  Preventive  treatment  should  be  adopted 
early,  although  the  disease  does  not  as  a  rule  appear  till 
later  life,  and  the  treatment  should  aim  mainly  at  influen- 
cing the  body  in  order  t'>  change  the  inherited  tendency 
towards  abnormal  metabolism  into  normal  metabolism. 
And  further  these  prophylactic  measures  are  indicated  in  a 
number  of  other  cases  where  the  individuals  are  not  known 
to  have  this  hereditary  taint  but  where  certain  signs 
point  to  a  predisposition  to  disease  of  metabolism.  We 
shall  return  to  this  subject  later. 

In  avoiding  external  injurious  factors  special  stress  has 
been  laid  upon  diet,  and  certain  foods  whose  metabolism 
can  in  such  affections  be  only  imperfectly  carried  out, 
were  altogether  excluded  from  the  diet  of  those  who  had 
any  tendency  to  diseases  of  metabolism. 

Apart  from  the  fact  that  we  have  now  given  up 
special  diets  in  the  treatment  of  diseases  of  metabolism, 
there  is  no  reason,  judging  from  the  aetiology  of  these 
diseases,  for  thinking  that  a  special  diet  is  called  for  in 
diseases  of  metabolism.  For  example  the  influence  of  carbo- 
hydrates upon  the  development  of  diabetes  seems  to  be 
negatived  when  we  consider  that  the  inhabitants  of  warm 
climates  live  principally  upon  carbohydrates,  and  yet 
the  cases  of  diabetes  among  them  are  not  more  numerous 
than  among  the  inhabitants  of  colder  countries  who  prefer 
a  meat  diet.  Some  statements  have  ascribed  to  diet  an  in- 
fluence in  the  development  of  diabetes,  as  for  example 
diabetes  is  said  to  be  very  common  in  Ceylon  (Hirsch)  ; 
also  in  Thuringia,  in  Normandy  and  in  some  districts  of 
England  where  purely  agricultural  pursuits  are  followed. 
On  the  other  hand  observations  have  shown  that 
diabetes  is  rare  in  some  conspicuously  agricultural  districts, 
such  as  the  Antilles  and  Brazil.  Among  Jews  we  find  a 
large  number  of  cases  of  diabetes,  indeed  the  influence  of 

100 


THE  PREVENTION  OE  THE  DISEASES  OF  METABOLISM 

race  aucl  of  heredity  is  so  great  in  diabetes  that  Senator 
maintains,  and  in  this  he  is  probably  right,  that  these  errors 
of  diet  give  rise  to  diabetes  only  because  great  over-loading 
of  the  gastro-intestinal  canal  with  purely  vegetable  food 
readily  leads  to  gastro-intestinal  affections,  which  then 
seem  sometimes  to  produce  diabetes  in  those  predisposed  to 
it  (Griesinger  and  Zimmer). 

The  influence  of  diet  has  been  emphasized  in  the 
aetiology  of  gout  even  more  than  in  diabetes,  especially  by 
English  writers  (Sydenham,  Grarrod),  who  regard  the  exces- 
sive use  of  meat  diet  as  the  chief  cause  of  gout,  and  therefore 
in  the  treatment  of  gout  recommend  abstinence  from  food 
which  contains  much  nitrogen.  Recently  we  have  given 
up  this  one  sided  idea  and  this  treatment  of  gout :  indeed 
certain  physicians  even  recommend  a  meat  diet  for  gout. 
We  now  know  that  gout  is  not  a  "privilege"  of  the  rich,  and 
that  it  occurs  more  often  than  was  formerly  assumed  among 
the  poor  who  have  never  known  luxury  and  the  excesses  of 
the  table.  Nevertheless  most  clinical  observers  take  the 
view  that  good  living  and  excessive  eating  and  drinking, 
even  though  they  be  not  the  exclusive  cause  of  gout,  yet 
have  a  certain  influence  upon  gout  and  especially  upon  the 
course  it  runs  by  causing  an  increased  formation  of  uric  acid. 
The  present  opinion  is  that  this  increased  formation  of  uric 
acid  in  the  body  is  not  the  ]3rimary  and  determining  factor 
in  gout  but  rather  the  secondary. 

First  there  occurs  some  injury  of  the  tissues,  especially 
at  the  articular  ends  of  bones,  the  cause  of  which  is  still 
unknown,  and  then  the  uric  acid  salts  crystallize  out  in 
these  tissues.  At  all  events  we  should  certainly  try  to 
limit  the  excessive  formation  of  uric  acid  in  gout  and  not 
allow  much  nitrogenous  food.  As  a  prophylactic,  those 
who  seem  predisposed  to  gout  should  observe  a  definite 
regimen.  Among  those  predisposed  some  have  an  heredi- 
tary tendency  to  gout,  such  that  they  show  signs  of  having 
a  "  gouty  diathesis  "  ;  they  are  people  of  luxurious  habits 
and  excreting  much  uric  acid.  Even  more  cases  belong 
to  the  class  who  have  already,  perhaps  many  years  before, 
had  a  typical  attack  of  gout  in  the  joint  of  the  great  toe 

101 


THE  PREVENTION   OE  DISEASE 

and  may  have  been  quite  free  from  trouble  since.  The 
diet  should  in  general  be  moderate :  meat  once  a  day  with 
the  principal  meal  is  sufficient ;  smoked  and  salt  meat  and 
fish  and  game  should  be  avoided  because  the  salts  and 
extractives  irritate  the  kidneys.  For  the  same  reason 
strong  cheese,  spices,  asparagus  and  celery  should  be  for- 
bidden. Spirits,  also  beer  and  heavy  wines,  should  not  be 
taken ;  light  moselle  wine  in  small  quantities  may  be 
allowed,  if  mixed  with  some  suitable  mineral  water,  such  as 
soda,  seltzer,  Biliner,  Fachinger  and  Giesshiibler. 

"With  regard  to  the  large  number  of  articles  of  diet 
recommended  or  forbidden  in  gout  and  in  the  gouty  dia- 
thesis we  still  do  not  know  the  reasons  and  explanations  of 
their  therapeutic  and  jDrophylactic  value.  A  difference  has 
been  made  between  white  and  red  meat,  because  white  meat 
contains  a  smaller  proportion  of  extractives  and  is  therefore 
said  to  be  preferable  in  gout ;  for  the  same  reason  boiled 
meat  is  better  than  raw  or  roast  meat.  The  nuclein  of  the 
cell-nuclei  appears  to  supply  the  material  wanted  by  the 
organism  for  the  formation  of  uric  acid,  and  Weintraud  has 
shown  that  by  giving  food  rich  in  nuclein,  the  excretion  of 
uric  acid  may  be  doubled  in  amount  or  more.  The  glandu- 
lar organs  which  are  rich  in  nuclein — thymus,  liver, 
kidneys  and  spleen — are  therefore  forbidden  to  the  gouty ; 
and  the  same  is  true  of  the  roe  of  fish  and  caviare.  Fat 
was  formerly  banished  from  the  diet  of  gouty  j)eople,  for 
according  to  Cantani  the  oxidation  of  nitrogenous  foods  was 
interfered  with  by  the  more  readily  oxidized  fat.  Ebstein 
has  again  introduced  fat  into  the  diet  for  gout ;  but  he  and 
Pfeiffer  on  the  whole  reject  carbohydrates,  while  other 
writers  allow  them. 

From  these  contradictory  statements  and  opinions  of 
different  writers  as  to  the  diet  for  gout,  we  gather  the  gen- 
eral principle  that  all  excess  both  in  the  quality  and  the 
quantity  of  food  must  be  avoided  and  a  regular  and  simjDle 
diet  adopted  ;  "  ordinary  homely  fare  "  best  fulfils  the  indi- 
cations, it  guards  us  from  unnecessary  limitation  in  diet  and 
also  from  eating  too  much. 

The    quantity    and    nature    of    the   food   are   certainly 

102 


THE  PEEVENTION  OF  THE  DISEASES  OF  METABOLISM 

factors  in  tlie  prophylaxis  and  in  the  treatment  of  gout,  as 
weJl  as  in  the  prevention  of  diabetes  and  obesity.  There 
is  no  doubt  that  occasionally  a  grave  error  in  diet  may 
cause  a  gradual  or  sudden  attack  of  gout ;  but  as  it  is  a 
constitutional  disease,  it  follows  that  prophylactic  measures 
must  affect  parts  of  the  body  where  metabolism  occurs,  and 
improve  the  activity  of  those  structures  if  metabolism  is  to 
be  normal.  It  is  therefore  essential  to  assist  the  excretion 
of  the  products  of  metabolism  by  suitable  means  and  thus 
avoid  accumulations.  The  best  means  of  promoting  meta- 
bolism is  muscular  activity.  Muscular  exercise  adapted  to 
each  individual  case  is  therefore  of  paramount  value  in  the 
prevention  of  all  the  diseases  of  metabolism.  The  much 
disputed  question  of  the  relation  between  bodily  activity 
and  the  formation  and  output  of  uric  acid,  which  is 
answered  differently  by  different  writers,  is  not  of  any 
importance  so  far  as  gout  is  concerned.  G-eneral  metabolism 
is  probably  always  greatly  increased  by  muscular  activity : 
the  flow  of  blood  and  lymph,  and  the  respiration,  are 
increased,  the  oxidation  processes  occurring  in  the  tissues 
are  more  thorough,  and  the  removal  of  effete  material 
from  the  body  is  promoted.  Useless  putting  on  of  fat,  to 
which  there  is  a  tendency  in  those  predisposed  to  gout  and 
to  diabetes,  is  prevented  by  muscular  activity  ;  and  it  also 
tends  to  prevent  the  various  obstructions  to  the  venous  circu- 
lation so  common  in  these  patients  ;  such  as  haemorrhoids, 
varicose  veins  and  congestion  of  the  liver.  The  muscular 
exercise  prescribed  for  each  patient  must  be  according  to 
the  functional  activity  of  his  muscles  and  of  his  heart ; 
those  who  lead  a  sedentary  mode  of  life  require  games  and 
recreation  which  need  only  moderate  effort,  and  in  which  all 
the  miuscles  of  the  body  are  exercised ;  these  are  especially 
swimming,  gymnastics,  rowing,  games  at  ball.  Cycling 
does  not  exercise  the  whole  body,  and  walking  does  so  still 
less  ;  but  these  will  probably  have  to  suffice  in  the  case  of 
elderly  people  accustomed  to  taking  things  easily,  and  a  fe-w 
exercises  at  home,  such  as  dumbbells  and  Swedish  gymnastics 
might  perhaps  be  added.  In  addition  to  increased  muscular 
activity,  hydropathic   treatment    is    a  valuable    means  of 

103 


THE  PREVENTION  OF  DISEASE 

promoting  metabolism  and  therefore  indicated  in  the 
prophylactic  treatment  of  diseases  of  metabolism.  In 
those  predisposed  to  gout,  great  care  must  be  taken  to  avoid 
cold,  because  experience  has  shown  that  cold  may  bring  on 
an  attack  of  gout ;  it  is  best  therefore  to  commence  with 
daily  lukewarm  partial  bathing  and  very  gradually  lead  up 
to  washing  with  cold  water,  followed  by  friction.  Cold 
baths,  especially  sea  baths,  are  not  advisable  for  those  who 
are  predisposed  to  gout,  as  they  make  great  demands  upon 
the  activity  of  the  vascular  system  and  heart.  In  general 
those  who  are  inclined  to  obesity  bear  cold  baths  better, 
and  sea  baths  are  often  very  useful — but  on  no  account 
should  they  be  prescribed  for  old  people  or  for  those  in  whom 
vascular  changes  exist.  The  whole  body  may  be  rubbed 
down  with  cold  water,  and  tepid  baths  of  short  duration  at 
about  85°  F.  may  be  taken,  and  the  temperature  may 
gradually  be  reduced  even  lower.  The  action  of  this  cold 
water  treatment  is  refiexly  to  deepen  the  respiration  and 
to  strengthen  and  slow  the  heart's  action,  and  thus  improve 
the  circulation ;  further  it  acts  upon  the  cutaneous  vessels, 
causing  them  to  contract  and  afterwards  to  dilate  after 
drying  and  rubbing,  and  thus  also  it  improves  the  circula- 
tion and  thereby  promotes  metabolism.  The  feeling  of 
well-being  which  this  treatment  gives  is  also  of  value,  and 
with  it  comes  a  natural  desire  for  bodily  movement 

Very  recently  some  drugs  have  been  introduced  as 
prophylactics  in  gout,  with  the  idea  of  preventing  the  for- 
mation of  uric  acid  in  the  body ;  for  the  many  attempts  to 
render  uric  acid  soluble  by  administering  lysidin,  piperazin, 
or  salts  of  lithia,  and  so  to  remove  the  tendency  to  gout  gave 
no  good  results  ;  as  however  great  was  the  power  of  these 
substances  to  dissolve  uric  acid  in  the  test  tube,  they 
proved  useless  when  introduced  into  the  human  body. 
Weiss,  while  recently  working  in  Bunge's  laboratory,  dis- 
covered that  quinic  acid  checks  the  formation  of  uric  acid 
in  the  body ;  and  hippurates  which  are  readily  soluble  in 
water  are  formed  instead.  Quinic  acid  is  present  in  lemons 
and  in  many  other  fruits,  and  this  is  probably  the  explana- 
tion of  the  good  effects  of  fruit-cures  which  have  been  so 

104 


THE  PREVENTION  OF  THE  DISEASES  OF  METABOLISM 

long  used  for  gout.  Quinic  acid  can  be  combined  with 
various  other  substances,  for  instance  with  piperazin,  and 
this  new  product  called  "  sidonal "  is  now  being  manufactured 
and  can  be  bought.  The  results  so  far  seem  to  give  reason 
for  hoping  that  in  sidonal  we  have  really  a  remedy  for 
gout,  and  the  uric  acid  diathesis,  and  also  a  prophylactic 
against  attacks  of  gout,  as  the  drug  prevents  the  excessive 
formation  of  uric  acid  and  its  deposit  in  the  tissues.  The 
dose  is  60  to  120  grains  daily,  and  no  unpleasant  bye- 
effects  have  yet  been  noted.  It  is  recommended  that  the 
drug  be  given  for  several  weeks  consecutively. 

The  preventive  treatment  of  obesity  and  corpulence 
requires  a  few  words  more.  There  is  not  a  tendency  to 
corpulence  in  all  people,  for  in  most  we  find  that  in  spite 
of  all  endeavours  to  put  on  fat  no  such  increase  takes  place, 
and  the  body  maintains  a  constant  balance  between  intake 
and  output.  Prophylactic  measures  are  indicated  for  all 
people  in  whose  families  obesity  is  common  ;  the  predisposi- 
tion to  it  does  not  usually  appear  during  the  earlier  years 
of  life  but  becomes  evident  in  the  middleaged.  Neverthe- 
less such  people  should  early  begin  to  carry  out  the  above 
mentioned  prophylactic  measures  to  strengthen  their  con- 
stitutions and  to  check  the  hereditary  tendency.  Sex 
appears  to  make  no  difference.  Yet  there  is  a  great  tendency 
to  obesity  among  women  at  the  period  of  the  menopause. 
We  do  not  yet  understand  the  reason  for  the  connection 
which  exists  between  the  menopause  and  obesity ;  but 
there  is  no  doubt  about  the  fact.  It  appears  to  be  related 
to  certain  results  brought  about  by  the  administration  of 
ovarian  extracts  as  previously  recommended  by  Landau  for 
the  ordinary  troubles  of  the  climacteric.  P.  F.  Richter  and 
Lowy  proved  that  the  metabolic  processes  in  animals 
after  ovariotomy  could  be  considerably  influenced  by  feed- 
ing them  with  ovarian  extract :  a  decided  increase  in  tissue 
oxidation  was  found  to  occur  in  the  animal.  These  results 
suggest  that  it  is  possible  that  tabloids  of  ovarian  extract 
given  at  the  menopause  may  serve  to  prevent  or  to  diminish 
the  excessive  formation  of  fat,  but  we  are  still  without 
clinical  observations  on  this  subject.     Thirdly,  prophylactic 

105 


THE  PREVENTION   OF  DISEASE 

measures  against  corpulence  are  indicated  for  those  who 
have  akeady  in  youth  shown  a  strong  tendency  to  obesity, 
which  increases  with  advancing  years.  Boys  and  girls 
alike  show  this  tendency,  and  no  hereditary  taint  can  as  a 
rule  be  discovered.  In  a  large  number  of  cases  this  exces- 
sive formation  of  adipose  tissue  is  accompanied  by  striking 
pallor  of  the  skin  and  weakness  of  the  muscles ;  in  many 
cases  we  find  also  congenital  abnormalities  of  the  generative 
organs,  such  as  retained  testes  or  absence  of  one  or  both 
testicles,  and  among  women  defective  functional  activity 
of  the  generative  organs  especially  manifesting  itself  by 
sterility. 

Finally,  a  number  of  cases  occur  in  men.  mostly  past 
middle  life,  of  phlegmatic  temperament  and  free  from  cares, 
who  habitually  eat  too  much  and  drink  too  much  (generally 
beer),  and  become  abnormally  fat.  In  these  cases  prophy- 
lactic measures  are  urgently  indicated  and  a  change  of 
living  is  followed  by  marked  improvement. 

Seeing  that  there  are  different  causes  producing  obesity, 
no  definite  scheme  of  prophylactic  and  therapeutic  measures 
can  be  drawn  up  to  suit  all  cases  ;  each  must  be  considered 
by  itself.  But  in  all  cases  it  is  true  that  very  severe  forms 
of  treatment  for  the  removal  of  obesity  are  harmful.  In 
the  matter  especially  of  diet  no  general  rules  can  be  laid 
down,  but  energetic  measures  in  connection  with  the 
quantity  of  food  are  best  adapted  for  the  last  class  of  cases 
which  result  from  habitual  over-eating  and  drinking.  A 
large  number  of  courses  at  one  meal  should  be  forbidden 
and  a  simple  diet  recommended.  The  influence  of  liquids 
upon  the  formation  of  adipose  tissue  has  long  attracted  the 
attention  of  physicians,  and  the  general  opinion  is  that 
imbibing  much  liquid  promotes  the  formation  of  fat.  In 
Schroth's  method  the  quantity  of  fluid  allowed  is  very 
small ;  and  Oertel  also  restricts  it  considerably.  Probably 
drinking  at  meals  improves  the  appetite  and  the  digestion. 
Some  restriction  of  the  quantity  of  fluid  taken  is  therefore 
generally  indicated  as  a  preventive  of  obesity,  especially 
for  heavy  eaters.  Spirits  and  beer  should  be  altogether 
forbidden.     A  small  quantity  of  a  light  acid  wine  may  be 

106 


THE  PEEVENTION  OE  THE  DISEASES  OF  METABOLISM 

permitted  at  meals.  In  tlie  choice  of  a  diet  the  aim  is  to 
supply  only  as  much  heat-formiug  food  as  the  body 
requires,  and  to  prevent  anything  that  would  cause  fat. 
Formerly  very  strict  rules  were  laid  down,  and  certain 
forms  of  food  were  absolutely  prohibited.  Sometimes  only 
carbohydrates  with  very  little  fat  were  allowed,  sometimes 
no  carbohydrates,  sometimes  only  nitrogenous  food  and 
carbohydrates.  Now  that  we  know  that  fat  may  be 
formed  from  any  one  of  the  three  chief  forms  of  food  when- 
ever more  food  material  is  taken  than  is  required  for 
purposes  of  combustion,  we  no  longer  prescribe  any  special 
dietary,  but  we  are  able  to  reach  the  same  end  by  other 
means  adapted  to  the  individual  case.  Ebstein's  recom- 
mendation of  giving,  in  addition  to  meat  and  other 
nitrogenous  foods,  much  fat  and  little  carbohydrate  food, 
is  at  all  events  chiefly  based  upon  the  fact  that  fat  acts  as 
an  aperient ;  but  many  people  soon  get  gastro-intestinal 
disorders  from  eating  much  nitrogenous  and  fatty  food, 
and  cannot  therefore  adopt  this  treatment.  Carbohydrates 
ill  any  case  should  be  more  or  less  limited,  they  are 
readily  absorbed  and  undergo  oxidation  easily,  and  thus 
diminish  the  oxidation  of  the  fat  ;  they  may  be  much 
restricted  in  those  who  are  otherwise  strong  and  healthy 
and  are  large  eaters.  Carbohydrates  niaj  also  be  limited 
in  women  at  the  climacteric,  but  they  should  be  less 
restricted  in  amount  in  weak  anaemic  persons,  and  in 
those  who  have  a  family  predisposition  to  corpulence  but 
are  not  themselves  yet  very  fat.  In  these  it  may  even  be 
dangerous  to  restrict  the  amount  of  carbohydrates  ;  a 
regular  diet  comprising  the  three  forms  of  food  is  required, 
and  the  body  must  be  kept  free  from  all  disorders  of  the 
digestive  apparatus  —  its  strength  be  maintained  and 
increased.  A  sim23le  regular  fare  is  required  with  no 
spirits  and  no  excess  of  any  kind,  and  the  measures 
previously  recommended  for  improving  metabolism  are 
most  necessar3^  In  this  class  of  cases  we  meet  with  those 
severe  forms  of  obesit}^  in  which  there  is  a  progressive 
deposit  of  fat  and  fatty  degeneration  of  organs  at  the  same 
time,  even   of   the   most  important,   especially   the   heart. 

107 


THE  PEEVENTION   OF  DISEASE 

The  fat  invades  the  structures  and  causes  their  elements  to 
disappear.  These  forms  of  obesity  do  not  depend  much 
upon  the  nature  of  the  food  taken. 

The  best  way  of  preventing  diseases  of  metabolism  would 
be  to  prevent  marriage  between  individuals  who  have  or 
have  had  these  diseases  or  who  are  hereditarily  predisposed 
to  them.  But  this  is  not  a  reasonable  suggestion  for 
general  application ;  moreover  heredity  does  not  always 
appear  in  the  direct  line  of  descent :  it  makes  leaps,  and 
sometimes  spares  a  whole  generation,  or  sometimes  a  number 
of  individuals  in  one  generation.  Moreover  we  often  see 
how  a  certain  predisposition  in  one  parent  is  compensated  for 
by  the  other  healthy  parent,  and  a  child  of  sound  con- 
stitution is  born  to  them.  The  laws  of  heredity  are  still 
exceedingly  obscure,  and  we  do  not  know  enough  to  enable 
us  to  arrive  at  any  definite  conclusions  yet ;  but  with 
regard  to  the  severer  disorders,  diabetes  and  gout,  we  may 
assert  that  marriage  between  two  who  are  predisposed  to 
these  diseases  or  have  already  suffered  from  either  of  them 
should  be  avoided.  Further  we  know  that  diabetes  and 
gout  have  certain  aetiological  relations  to  mental  and 
nervous  disorders,  so  that  in  some  families  all  these  varieties 
of  disease  are  met  with.  As  a  prophylaxis  marriage  should 
therefore  be  avoided  between  persons  in  whom  there  is  on 
both  sides  a  predisposition  to  these  constitutional  diseases, 
especially  to  diabetes  and  gout. 


108 


The  Prevention  of  Infectious  Diseases 

BY 

DE.   RICHAED   ROSEN 

This  article  has  been  slightly  modified  with  the  view  of  rendering- 
it  more  applicable  to  the  English  reader. 


109 


The  Prevention   of  Infectious    Diseases 

From  what  was  said  before  concerniiig  infectious  diseases,  it 
follows  that  the  principles  which  guide  us  in  their  prophy- 
lactic treatment  are  similar  to  those  in  the  case  of  other 
diseases  ;  but  in  addition  we  need  to  guard  against  the 
external  injurious  influences,  the  pathogenic  bacteria.  It 
is  essential  also  to  employ  means  to  raise  the  powers  of 
resistance  of  the  individual  and  to  assist  the  constitution  in 
its  battle  against  the^injurious  influence.  But  in  infective 
diseases,  the  external  injurious  factor — infection  by  the 
invasion  of  the  body  by  special  bacteria — is  probably  a 
more  prominent  factor  than  the  constitutional  one,  and  our 
prophylaxis  is  essentially  a  battle  against  infection.  The 
best  protection  against  infection  would  be  the  destruction  of 
the  infective  material.  This  is  the  work  really  of  public 
hygiene,  and  it  endeavours  to  remove  by  sanitation  the  con- 
ditions necessary  for  the  growth  of  the  germ ;  by  the  removal 
of  refuse,  filtration  ol  drinking  water,  and  similar  measures 
which  aim  at  keeping  the  bacteria  and  their  toxins  from 
coming  into  contact  with  human  beings.  And  indeed  such 
precautions  taken  by  the  State  and  by  district  authorities 
have  succeeded  in  almost  entirely  stamping  out  certain 
infective  diseases,  the  infective  agents  and  the  mode  of  in- 
fection of  which  are  known.  For  example,  when  it  was 
recognized  that  specifically  infected  drinking  water  was  the 
most  frequent  cause  of  epidemics  of  typhoid  fever,  some 
towns  provided  a  supply  of  pure  water,  and  such  epidemics 
ceased  almost  entirely. 

Ill 


THE  PREVENTION   OF   DISEASE 

Iiidi vicinal  prophylactic  measures  have  for  their  object 
the  protection  of  the  individual  himself  against  infection. 
The  methods  depend  upon  the  manner  in  which  the 
various  infective  diseases  are  conveyed,  and  will  differ 
according  as  the  infection  is  conveyed  by  the  air,  as  in 
smallpox,  or  chiefly  by  the  evacuations,  as  in  cholera. 
For  purposes  of  prophylaxis,  infectious  diseases  may  be 
grouped  into  those  the  germs  of  which  are  carried  by  the  air 
and  those  in  which  the  germs  are  conveyed  by  some  solid 
or  liquid,  whether  the  diseased  body  itself  or  some  of  its 
excretions  or  secretions.  Though  all  infective  diseases  do 
not  fit  at  all  accurately  into  this  scheme,  yet  we  can  on 
this  principle  arrange  them  provisionally  somewhat  as 
follows,  the  channels  given  being  the  main,  but  not  the 
only,  media  of  infection — 


A.  Infection  is  conveyed  in 


Measles 

Scarlatina 

Smallpox 

Chickenpox 

Typhus  fever 

Whooping  cough 

Influenza 

Epidemic  pneumonia 

Mumps 

Diphtheria 

Cerebro-spinal  fever 

Pneumonic  plague 

Internal  anthrax 


\ 


mainly  by  the  air,  and  by 
the  secretions  given  off  by 
the   invaded   membranes  or 


organs. 


B. 


Enteric  fever 
Cholera 
Dysentery 
Communicable  diarrhoea 


by  the  excreta,  and  by 
articles,  foods,  and  drinks 
infected  thereby. 


112 


THE   PREVENTION   OF  INEECTIOUS  DISEASES 


C. 


Glanders 

Syphilis 

Gonorrhoea 

Contagions  ophthalmia 

Pnerperal  fever 

Tetanus 

Erysipelas 

External  anthrax 

Bubonic  plague 


mainly  by  inoculation  with 
the  infected  secretions,  but 
certain  of  these  diseases  may 
be,  at  times,  air-borne. 


D. 


Malaria 
Yellow  fever 
Filariasis 


1  by  the  bites  of  mosquitoes,  acting  as 
r  the  intermediate  host  of  the  specific 
J    parasite. 


Protection  against  infection  must  be  according  to  the 
method  or  methods  in  which  the  infection  is  conveyed  :  in 
diseases  of  the  first  group  A,  in  which  infection  is  through 
the  air  from  man  to  man,  infection  may  also  occur  as  in 
group  B  or  C  by  means  of  soiled  linen  used  by  the  patient ; 
the  secretions  from  the  mouth  and  nose  also  of  these 
patients  are  infective.  Therefore  in  all  infective  diseases, 
almost  without  exception,  utensils  should  be  set  apart  for 
the  patient  alone  and  not  be  taken  into  general  use,  and  all 
soiled  linen,  rags  or  utensils  should  be  burned  or  disinfected. 
All  who  are  brought  into  contact  with  infectious  disease 
should  carefully  wash  their  hands  and  cleanse  their  nails 
before  meals,  and  should  avoid  touching  their  mouths  with 
their  fingers ;  in  the  sickroom  the  attendants  should  wear 
linen  overalls  over  their  ordinary  clothes. 

For  diseases  where  the  infection  is  conveyed  through  the 
air,  the  safest  mode  of  prevention  is  the  isolation  of  the 
patient,  although  theoretically  perfect  isolation  cannot  be 
carried  out,  as  the  attendants  themselves  are  liable  to  carry 
infection  without  themselves  being  ill.  In  small  houses, 
where  it  is  impracticable  to  afford  one  or  two  rooms  for  the 
sole  use  of  the  patient  and  his  attendant,  it  is  desirable 
that  the  patient  should  be  removed  to  an  isolation  hospital, 

113  I 


THE  PREVENTION  OF  DISEASE 

and  the  room  and  infected  articles  thoroughly  disinfected  by 
the  sanitary  authority.  But  where  there  is  no  such  hospital 
accommodation  a  room  as  far  removed  from  the  rest  of  the 
household  as  possible  should  be  set  aside  for  the  use  of  the 
patient,  and  an  attendant,  preferably  one  who  has  already 
suffered  from  the  disease,  or  is  likely  to  be  relatively 
insusceptible  to  it,  should  be  told  off  to  take  charge  of  him. 
In  scarlatina  the  desquamated  cuticle  is  still  regarded  as 
one  of  the  means  of  conveying  infection,  but  infection  is  also 
situated  in  the  secretions  from  the  nasal  and  aural  passages  in 
cases  where  the  patient  suffers  from  rhinorhoea  or  otorrhoea. 

When  the  infective  material  is  air-borne  and  reaches  the 
patient  directly  by  the  air,  it  is  difficult  to  ensure  absolute 
protection  against  it  from  isolation  of  the  patient.  For 
example,  in  epidemics  of  influenza  we  must  assume  that  the 
germ  of  influenza  is,  if  not  ubiquitous,  at  least  very  generally 
diffused.  Much,  however,  may  be  done  by  preventing  the 
gathering  together  of  large  bodies  of  persons  and  by  the 
isolation  of  those  affected  with  the  disease. 

The  infection  of  erysipelas  is  perhaps  liable  to  be  spread 
directly  by  the  air,  but  conveyance  of  the  infection  from 
person  to  person  by  direct  contact  or  close  proximity  is 
probably  more  frequent.  Just  as  in  hospitals,  strict  isola- 
tion of  erysipelas  cases  is  enforced,  so  also  in  private 
practice  the  patient  should  be  isolated  ;  very  strict  and 
thorough  methods  of  disinfection  are  essential,  and  band- 
ages and  dressings  should  be  burnt  directly  after  removal. 

In  infective  diseases  where  the  infectious  material  is  not 
carried  by  the  air  there  is  no  danger  from  proximity  to  the 
patient.  If  infection  is  situated  only  in  the  affected  part  of 
the  body,  for  example  in  gonorrhoea  and  in  syphilis,  prophy- 
laxis is  merely  required  to  prevent  direct  contact  of  a  healthy 
body  with  the  affected  part,  or  the  discharges  therefrom. 
For  infective  diseases  which  are  conveyed  to  man  from 
animals,  such  as  hydrophobia,  glanders  and  anthrax,  pro- 
phylactic measures  should  include  the  destruction  of  the 
diseased  animals,  and  also  public  regulations  for  the  pre- 
servation of  health,  such  as  the  compulsory  muzzling  of 
dogs  and  other  suitable  precautions. 

114 


THE  PREVENTION   OF  INFECTIOUS  DISEASES 

Wiien  the  germs  of  the  disease  are  conveyed  chiefly 
through  the  evacuations  of  the  patient  the  prophylactic 
measures  are  obvious.  Among  these  diseases  are  typhoid 
fever,  dysentery  and  cholera,  "where  the  evacuations  from 
the  bowels  contain  and  spread  the  infection,  as  also  may 
the  vomited  matter  in  cholera.  Another  member  of  this 
class  is  diphtheria,  in  which  the  poison  is  contained  in  the 
secretions  of  the  mouth  and  nose  ;  and  to  some  extent  also 
pulmonary  tuberculosis  may  be  considered  as  belonging  to 
this  group,  for  this  disease  is  mainly  spread  by  the  sputum 
of  the  patient. 

In  the  case  of  typhoid  fever,  cholera  or  dysentery,  or  in 
conditions  in  which  one  or  other  of  these  diseases  is  sus- 
pected, the  excreta  (in  typhoid  fever  including  the  urine) 
should  be  received  into  a  vessel  containing  a  small  amount 
of  some  efficient  disinfectant,  such  as  carbolic  acid  (5  per 
cent.)  or  acidulated  perchloride  of  mercury  (1  in  1000). 
After  the  motion  has  been  passed,  more  of  the  disin- 
fectant solution  should  be  added,  the  whole  being  intimately 
mixed  together  and  allowed  to  stand  for  some  thirty 
minutes.  Care  should  be  taken  that  sufficient  disinfectant 
is  added  to  prevent  the  percentage  strength  of  the  mixture 
being  reduced  below  its  limit  of  efficiency  by  dilution  with 
the  excreta.  The  contents  of  the  bed-pan,  or  other  receptacle, 
may,  after  disinfection,  be  emptied  down  the  slop-sink  or 
water-closet  where  there  is  a  proper  system  of  sewers ;  but 
in  rural  districts  where  drains  or  sewers  do  not  obtain,  the 
excreta  may  be  buried  in  shallow  holes  dug  in  the  ground 
sufficiently  remote  from  wells  or  other  sources  of  water 
supply.  It  must  be  borne  in  mind  that  the  disinfectant 
itself,  altogether  apart  from  the  specific  virus  of  the  disease, 
may  seriously  endanger  the  purity  of  a  water  supply.  The 
soiled  bed  and  body  linen  should  at  once  be  soaked  in  a  vessel 
of  soap  and  water,  and  the  articles  be  subsequently  raised  to 
the  boiling  point  during  the  washing  process.  Soiled  articles 
of  bedding  such  as  mattresses  and  blankets  which  cannot  be 
thus  treated  should  either  be  handed  over  to  the  sanitary 
authority  for  disinfection  in  a  steam  apparatus  or  be 
destroyed  by  fire.     In  these  three  diseases,  namely  typhoid 

116 


THE  PREVENTION   OE  DISEASE 

fever,  dysentery  and  cholera,  the  physician  may  generally 
prevent  any  further  extension  of  the  disease  by  giving  exact 
rules  to  be  followed  by  all  the  members  of  the  household. 
"  When  cholera  is  prevalent  the  family  physician,  as  the 
friend  of  the  household,  can  guard  the  inmates  in  a  way 
scarcely  possible  at  other  times  "  (Leber t).  These  indica- 
tions of  the  way  in  which  individuals  may  be  protected 
against  direct  infection  will  suiEce  here.  Much  the  same 
is  true  of  diphtheria,  but  in  that  disease  the  linen  and 
the  plates  and  drinking  vessels  require  special  disinfection, 
while  the  excreta  do  not.  Healthy  people  must  be  specially 
warned  against  coming  near  the  patient's  face  when  he 
coughs. 

In  tuberculosis,  too,  infection  may  be  conveyed  by 
coughing,  small  droplets  of  fluid  carrying  tubercle  bacilli 
being  cast  into  the  are,  and  inspired  by  healthy  persons. 
Fltigge  has  recently  drawn  special  attention  to  this  mode 
of  infection,  which  he  considers  far  more  dangerous  than 
that  by  dried  sputum  or  dust.  As  a  result  of  Fliigge's 
work,  B.  Frankel  has  introduced  a  mask  which  is  some- 
what similar  in  form  to  Schimmelbusch's  chloroform  mask, 
is  covered  with  two  layers  of  thick  muslin,  and  fastened 
around  the  ears  or  the  head  by  an  elastic  band.  The  mask 
covers  only  the  mouth  and  leaves  the  nose  free.  The 
material  can  be  easily  removed  and  replaced  by  a  new 
piece.  It  is  proposed  that  this  mask  should  be  worn  by 
patients  who  expectorate  much  and  have  advanced 
phthisis,  because  apart  from  the  act  of  expectoration,  the 
small  drops  of  fluid  containing  tubercle  bacilli  which  are 
often  thrown  out  in  speaking,  coughing,  and  in  clearing 
the  throat,  would  be  stopped  by  the  mask.  Fliigge's  and 
B.  Frankel's  experiments  seem  to  show  that  patients  with 
early  phthisis  do  not  convey  infection  in  this  way. 

Nevertheless  all  phthisical  patients  should  be  reminded 
by  the  physician  to  hold  the  hand  before  the  mouth  when 
coughing,  and  so  far  as  possible  to  suppress  coughing  in 
the  presence  of  others.  A  little  practice  will  enable  the 
patient  to  do  this. 

Other  ways  in  which  tuberculous  infection  is  conveyed, 

116 


THE   PREVENTION  OF  INFECTIOUS  DISEASES 

and  the  prevention  of  infection,  will  be  described  later  in 
connection  witli  the  prophylaxis  of  tnbercnlosis. 

Wliile  prophylactic  measures  are  being  taken  against  the 
agents  which  cause  infection  and  are  mainly  applicable 
to  the  bodies  of  those  vdio  are  already  affected,  other  pre- 
cautions should  at  the  same  time  be  taken  to  strengthen 
against  disease  the  bodies  of  those  who  are  healthy,  making 
them  as  it  were  proof  against  infection  and  removing  or 
reducing  the  predisposition  to  disease.  On  the  other  hand 
the  healthy  body  must  be  guarded  from  everything  which 
would  call  forth  or  increase  predisposition  to  the  disease. 
Prophylactic  measures  such  as  these  for  the  healthy  body 
are  of  especial  value  in  cases  where  it  is  not  possible  to  do 
much  or,  indeed,  anything  against  the  infective  agents, 
especially  when  they  are  conveyed  through  the  air. 

The  object  of  prophylactic  treatment  in  this  connection 
is  twofold :  to  prevent  the  poison  from  entering  the  body 
by  the  ordinary  channels  and  to  keep  these  channels  in 
normal  conditions.  The  healthy  mucous  membrane  is  able 
to  resist  many  injurious  influences  and  often  even 
pathogenic  bacteria.  During  cholera  epidemics  numbers  of 
cholera  bacilli  are  said  to  have  been  found  in  the  evacua- 
tions of  healthy  people.  Pettenkofer  and  others  swallowed 
cultures  of  cholera  bacilli  and  were  not  attacked,  the  normal 
stomach  and  intestines  were  able  to  prevent  the  bacteria 
from  getting  into  the  tissues.  The  conditions  of  the 
mucous  membrane  which  permit  the  entry  of  bacteria  into 
the  organism  may  be  temporary  or  permanent,  and  may 
be  the  result  of  some  anatomical  lesion  or  of  some  functional 
change.  To  take  cholera  as  an  example,  experience  has 
taught  us  that  gastric  and  intestinal  catarrh  favour  the 
development  of  cholera,  for  the  diseased  mucous  membrane 
cannot"  withstand  the  infective  agents.  In  times  of  cholera 
all  errors  of  diet  should  be  avoided  and  forms  of  food 
likely  to  start  diarrhoea,  such  as  cucumbers,  melons,  and 
unripe  fruits  and  acid  beverages.  Taking  cold,  over- 
exertion, and  mental  emotions  also  readily  exert  a  bad  in- 
fluence upon  the  functions  of  the  stomach  and  intestines, 
and  a  regular  quiet  life  with  moderation  and  care  in  every 

117 


THE  PREVENTION  OF  DISEASE 

respect  is  therefore  to  be  recommended.  But  the  ordinary 
way  of  living  should  on  no  account  be  altered  if  it  is  normal 
and  sensible.  Not  only  do  such  injurious  influences  which 
are  accidental  and  temporary  act  upon  the  gastro-intestinal 
canal  and  predispose  to  the  disease,  but  permanent  abnormal 
conditions  act  similarly;  for  persons  with  "weak"  stomachs 
or  with  well  marked  affections  of  the  stomach  or  intestines 
are  very  apt  to  sicken  with  cholera.  At  such  times  weak 
and  delicate  people  should  be  recommended  to  have  a  diet 
adapted  to  their  individual  needs,  and  to  take  wine,  and 
small  quantities  of  rum  or  brandy  in  their  tea,  keeping  the 
feet  and  the  body  warm.  Every  disorder,  even  those 
apparently  trivial,  especially  when  affecting  the  stomach 
and  intestines,  should  receive  careful  treatment. 

Similar  precautions  are  required  in  epidemics  of  typhoid 
fever  and  dysentery  ;  here  as  in  cholera  infection  enters  by 
way  of  the  digestive  tract.  In  sporadic  cases  of  typhoid 
fever  early  and  thorough  disinfection,  together  with  the 
other  rules  given  above  for  destroying  the  infective  material, 
will  sufi&ce. 

Accidental  lesions  of  the  skin  or  mucous  membrane 
which  permit  of  the  entry  of  infection  are  often  so  trivial 
as  to  be  easily  overlooked.  In  erysipelas  of  the  face  the 
disease  starts  at  some  minute  excoriation  of  the  skin 
especially  at  the  nostril,  so  common  in  an  ordinary  nasal 
catarrh.  Special  care  should  be  taken  when  a  patient  who 
has  once  had  erysipelas  gets  a  nasal  catarrh,  because 
erysipelas  belongs  to  those  diseases  which  leave  a  predisposi- 
tion to  a  second  attack.  The  nasal  catarrh  should  be 
carefully  treated,  the  nose  smeared  with  boro-vaseline,  and 
the  fingers  should  not  be  allowed  to  touch  the  face. 

To  keep  the  respiratory  organs  intact  is  of  great  im- 
portance in  influenza.  The  different  forms  in  which  in- 
fluenza manifests  itself  and  the  appearance  of  local  affec- 
tions in  addition  to  the  general  symptoms  may  indicate 
that  the  germs  of  influenza  can  enter  the  body  by  differ- 
ent channels.  It  is  remarkable  that  in  different  cases  of 
influenza  sometimes  the  digestive  tract  is  almost  exclusively 
affected,  sometimes  the  respiratory  system,  sometimes  the 

118 


THE  PREVENTION   OF   INFECTIOUS  DISEASES 

nervous  system.  The  metliocl  of  infection  in  influenza  is 
still  obscure,  but  many  observations  seem  to  point  to  infec- 
tion through  the  respiratory  tract.  It  has  been  shown 
that  those  are  specially  apt  to  get  influenza  who  have  also 
a  predisposition  to  colds,  to  bronchitis  and  laryngitis,  and 
those  who  have  some  acute  or  chronic  disease  of  the  upper 
respiratory  passages.  The  influenza  germs  which  may  be 
in  the  air  we  breathe  readily  attack  an  epithelial  surface 
already  pathologically  changed  and  thence  more  easily  pass 
into  the  lymph  stream.  This  is  in  accordance  also  with 
Breitung's  statement  that  those  children  are  particularly 
liable  to  be  attacked  by  influenza  whose  nasal  respiration 
is  hindered  by  swelling  of  the  turbinates  or  by  adenoid 
growths.  The  tonsils  are  regarded  as  a  locality  where  in- 
fluenza may  begin,  and  slitting  the  lacunae  has  been  recom- 
mended as  a  prophylactic.  Recently  in  the  Academic  de 
Medecine  at  Paris  the  subject  of  protection  of  the  individual 
against  influenza  was  discussed.  As  a  preventive  during 
epidemics  of  influenza,  Huchard  recommended  disinfection 
of  the  nose  and  mouth  with  antiseptic  solutions  ;  Labonde 
recommended  washing  out  the  nose  and  throat  twice  daily 
with  a  weak  hot  solution  of  carbolic  acid  (1  in  3,000) ; 
Huchard  considered  that  it  was  also  necessary  to  make  the 
digestive  tract  aseptic,  and  to  this  end  a  milk  diet  is  best ; 
the  usual  drugs  employed  for  this  purpose,  such  as  naphthol 
and  salol,  are  less  useful.  Breitung  regards  the  inhalation 
of  nascent  chloride  of  ammonium  from  a  special  apparatus 
an  effectual  protection  against  influenza  ;  those  whose 
profession  causes  any  special  strain  upon  the  organs  of 
respiration — as  teachers,  preachers  and  singers — and  who 
are  thereby  probably  predisposed  to  influenza  should  guard 
against  it  by  regularly  inhaling  ammonium  chloride. 

Not  only  in  influenza  but  also  in  other  infective 
diseases  the  tonsils  are  supposed  to  serve  as  a  place  for 
the  entrance  of  the  infection.  The  exciting  agents  which 
cause  measles  and  scarlet  fever,  often  seem  to  gain 
entrance  through  tonsillar  leisons,  and  so  too  does  the 
diphtheria  bacillus.  Affections  of  the  tonsils  whether  acute 
or   chronic  always  require  most  careful  treatment  ;    often 

119 


THE  PREVENTION   OE  DISEASE 

tliere  are  on  tlie  tonsils  deep  pockets  and  cliannels  whicli 
gradually  get  filled  with,  plugs  consisting  of  particles  of 
food  and  of  cellular  debris  which  are  undergoing  decom- 
position, smell  badly  and  keep  up  a  chronic  irritation  of  the 
tonsil.  These  pockets  must  be  slit  up  and  the  plugs 
removed.  The  further  treatment  is  that  for  chronic  inflam- 
mation of  the  tonsil — painting  with  solutions  of  alum  or 
silver  nitrate,  or  removal  of  the  tonsil  by  the  guillotine. 

Having  considered  thejDredisjDOsitionof  individuals  to  infec- 
tion through  the  condition  of  their  mucous  membranes,  we 
have  now  to  consider  another  kind  of  predisposition  wbich  is 
in  a  sense  less  definable  as  it  depends  upon  the  general  con- 
stitution. A  kind  of  general  weakness  in  many  cases  is 
the  basis  upon  which  this  predisposition  rests ;  it  is  very 
clearly  marked  in  pulmonary  tuberculosis  in  which  a  definite 
inherited  constitution  predisposes  to  the  disease.  Some- 
times predisposition  to  infective  diseases  is  the  result  of  a 
weakness  of  the  body  which  does  not  show  itself  by  any 
outward  signs  and  is  not  inherited ;  this  weakness  is  rather 
an  accidental  acquired  weakness  which  may  attack  even 
robust  natures.  For  example  we  know  that  lobar  pneu- 
monia often  results  from  a  plunge  into  cold  water  or  some 
other  excessive  chilling  of  the  body ;  and  so  too  does 
articular  rheumatism.  This  sudden  cooling  causes  a 
momentary  weakness  which,  makes  the  body  susceptible  to 
infection.  In  epidemics  it  has  often  been  observed  that 
people  fall  victims  to  the  infection  directly  after  some 
severe  over-exertion,  after  some  form  of  excess,  especially 
venereal  excesses  or  any  condition  which  has  weakened  the 
whole  body.  It  follows  that  during  epidemics  prophylaxis 
consists  in  avoiding  all  that  would  in  any  degree  reduce 
the  functional  activity  of  the  body. 

In  epidemics  we  see  one  sicken  with,  smallpox  or  scarlet 
fever,  while  another — perhaps  a  brother — remains  well ;  yet 
the  conditions  under  which  they  lived  and  their  mode  of 
life  were  exactly  th.e  same,  and  nei  ther  showed  any  signs  of 
ill  health  or  difference  in  bodily  condition.  Probably  there 
existed  some  very  minute  chemical  differences  in  the  blood 
and  lymph  which  made  the  one  susceptible  to  the  action  of 

120 


THE  PREVENTION   OF   INFECTIOUS  DISEASES 

the  infective  material.  Into  this  obscure  region  of  aetiology 
a  ray  of  light  has  recently  been  flashed  by  the  work  of 
Ehrlich,  Brieger,  Behring  and  others  who  have  shown  that  in 
the  blood  certain  chemical  bodies  (alexins)  act  under  special 
conditions  as  antidotes  to  certain  bacterial  poisons;  these 
alexins  are  derived  principally  from  cells,  mostly  the  white 
corpuscles  of  the  blood.  These  recent  aetiological  researches 
were  suggested  by  the  great  practical  results  which  followed 
the  use  of  inoculation  •  as  a  therapeutic  and  prophylactic 
measure  ;  the  substances  used  for  inoculation  stand  in  a 
definite  relation  to  the  infective  bacteria  or  to  their  j)roducts, 
and  when  injected  into  the  body  render  it  immune  against 
the  infective  poison.  In  this  way  we  imitate  nature's 
method  of  making  the  body  immune ;  this  immunity 
against  certain  infections  is  inherited  by  some,  by  others  it 
is  acquired — sometimes  because  they  have  already  had  that 
particular  disease,  as  in  smallpox,  measles,  scarlet  fever,  or 
typhoid.  In  other  cases  a  person  who  has  once  had  an 
infective  disease  is  more  predisposed  to  it  and  liable  to  have 
it  again,  as  in  articular  rheumatism,  erysipelas,  influenza 
and  diphtheria.  Sometimes  increased  predisposition  to  an 
illness  is  left  as  the  result  of  some  other  illness,  for  instance 
measles  predisposes  to  tuberculosis  ;  scarlet  fever  and  also 
measles  predispose  to  diphtheria  ;  measles  moreover  predis- 
poses to  whooping  cough. 

The  theory  of  preventive  inoculation  cannot  be  entered 
into  more  fully  here.  Until  a  few  years  ago  inoculation 
was  undertaken  only  against  smallpox,  but  of  late  years 
Pasteur,  Behring  and  others  have  inaugurated  a  new 
era  by  preventive  and  curative  inoculations  for  other 
infective  diseases.  The  great  practical  results  which  have 
followed  from  vaccination  against  smallpox  have  very  fre- 
quently been  quoted.  Vaccination,  where  properly  applied, 
has  brought  about  almost  the  extinction  of  a  disease  which 
in  the  eighteenth  century  and  in  the  beginning  of  the  nine- 
teenth century  was  one  of  the  commonest  and  most  dreaded  of 
diseases.  Cases  of  smallpox  which  occur  now  and  again  have 
always  been  traced  to  infection  brought  from  abroad,  especi- 
ally from  Russia,  where  compulsory  protective  inoculation 

121 


THE  PREVENTION   OF  DISEASE 

against  smallpox  (vaccination  and  revaccination)  has  not 
yet  been  introduced.  Among  the  most  ancient  civilized 
races— the  Chinese  and  the  Indians — there  was  practised  in 
prehistoric  times  a  method  by  which  an  attenuated  form  of 
the  poison  of  smallpox  was  employed  in  order  to  produce  a 
mild  form  of  "  sporadic  "  smallpox,  by  which  the  body  was 
rendered  immune  against  the  disease.  This  method  of 
inoculation  of  smallpox  (variolization)  was  introduced  into 
Europe  in  the  eighteenth  century,  but  was  subsequently  for- 
bidden by  law  because  of  the  danger  of  the  spread  of  small- 
pox by  its  employment.  In  1796  Jenner  introduced  the 
valuable  method  of  vaccination,  the  inoculation  of  human 
beings  with  the  infection  of  cowpox,  and  it  has  since  been 
scientifically  and  experimentally  proved  to  be  an  effectual 
protection  against  true  smallpox.  It  is  now  many  years 
since  vaccination  became  recognized  as  a  branch  of  public 
hygiene.  For  individual  prophylaxis  it  is  advisable  that 
everyone  should  be  revaccinated  before  going  into  countries 
where  there  is  smallpox,  because  after  the  lapse  of  a  certain 
period  vaccination  no  longer  affords  absolute  protection 
against  smallpox,  although  the  disease  runs  a  milder  course 
in  one  who  has  been  vaccinated.  Sometimes,  for  example 
in  India,  we  are  told  it  is  possible  for  white  men  who  have 
travelled  thither  to  be  susceptible  to  vaccination  on  their 
arrival,  though  attempts  to  vaccinate  them  failed  shortly 
before  they  started  from  home. 

The  modern  endeavours  by  bacteriologists  to  discover 
methods  of  protective  inoculation  against  other  infective 
diseases  by  strictly  scientific  methods  have  not  yet  led  to 
great  practical  results,  though  a  beginning  has  been  made 
which  augurs  well  for  the  future.  The  value  of  Pasteur's 
inoculations  against  hydrophobia  are  universally  acknow- 
ledged ;  the  method  has  been  successful  in  the  treatment 
of  several  thousands  of  people  bitten  by  animals  apparently 
suffering  from  rabies.  The  principle  upon  which  this 
treatment  by  inoculation  is  based  is  to  make  the  body 
immune  against  the  infection  by  giving  gradually  increas- 
ing doses  of  the  specific  antitoxin.  For  this  purpose  Pasteur 
used  the  spinal  cords  of  rabbits  infected  with  the  poison  of 
rabies ;  the  cord  was  exposed  to*a  drying  process  and  dried 

122 


THE   PEEVENTION   OF  INFECTIOUS  DISEASES 

for  different  periods  to  produce  virus  of  different  degrees 
of  virulence :  the  driest  is  the  least  potent.  Emulsions  of 
these  different  spinal  cords  were  then  injected  at  regular 
intervals  into  the  human  body.  In  Berlin  a  special  part 
of  the  Institute  for  Infectious  Diseases  is  now  reserved  for 
inoculation  against  hydrophobia,  and  any  one  in  G-ermany 
who  has  been  bitten  by  an  animal  which  has  or  is  suspected 
of  having  rabies  is  sent  to  the  institute  without  delay  for 
treatment.  The  value  of  Pasteur's  protective  inoculations 
against  anthrax  has  not  yet  been  fully  recognized.  Anthrax 
occurs  very  seldom  in  human  beings  and  the  method  is 
used  mostly  for  animals,  but  in  spite  of  the  incontrovertible 
results  obtained  in  the  laboratory  the  method  has  not 
yet  been  introduced  into  veterinary  practice. 

Behring's  serum  treatment  of  diphtheria  is  recognized 
by  all  to  be  most  valuable  and  successful,  but  the  proposed 
preventive  inoculation  against  diphtheria  has  not  as  yet 
been  generally  applied.  It  is  based  upon  the  same  principle 
as  curative  inoculation,  but  the  serum  contains  a  smaller 
number  of  units  of  the  virus  ;  in  children  250  units  are" 
generally  injected.  The  injected  serum  gives  immunity  for 
three  weeks,  and  the  inoculations  should  be  repeated  every 
three  weeks.  Further  details  about  this  subject  will  be 
found  in  the  section  on  Diseases  of  Children.  Preventive 
inoculation  against  diphtheria  is  rarely  required  for  adults. 

Quinine,  the  specific  drug  for  malaria,  is  also  highly 
valued  by  authorities  on  malaria  as  a  prophylactic  against 
this  disease.  Hertz  recommended  5  grains  of  quinine  every 
morning  and  evening  during  epidemics  in  malarial  dis- 
tricts, and  obtained  very  good  results — sometimes  no  attacks 
at  all  occurred,  sometimes  the  attacks  were  of  an  extremely 
mild  type.  After  using  the  drug  for  some  time  the  organism 
gets  habituated  to  it  and  the  drug  loses  some  of  its  efficacy, 
and  should  therefore  be  discontinued  for  two  or  three 
weeks  every  now  and  again.  For  the  ordinary  endemic 
attacks  of  malaria  a  longer  use  of  the  drug  is  not  of 
value  in  prophylaxis,  but  it  is  sufficient  directly  the  first 
symptoms  of  malaise  appear  to  give  10  grains  of  quinine 
in  the  evening  at  bedtime  for  three  or  four  consecutive 
days,  in  order  to  cut  short  the  attack. 

123 


The  Prevention  of  Pulmonary 
Tuberculosis 

The  great  frequency  of  pulmonary  tuberculosis  and  the 
great  mortality  caused  by  it  justify  us  in  devoting  a 
section  specially  to  the  prevention  of  this  most  serious  of 
all  infective  diseases.  There  are  even  now  those  who 
deny  the  infectious  nature  of  tuberculosis  and  look  upon 
the  disease  as  one  purely  constitutional.  Although  the 
constitution  is  an  important  aetiological  factor  in  tuber- 
•culosis,  yet  clinical  observation  and  experimental  research 
both  point  to  the  tubercle  bacillus  as  the  exciting  cause 
of  tuberculosis.  The  instincts  of  the  people,  which  are 
particularly  acute  in  such  matters,  long  ago  convinced 
them  that  pulmonary  consumption  is  communicable.  The 
whole  of  our  knowledge  points  strongly  to  the  conclusion 
that  prophylaxis  must  concern  itself  with  preventing  the 
tubercle  bacillus  from  entering  the  human  body.  We 
must  endeavour  to  render  innocuous  the  excretions  and 
evacuations  of  the  patient  which  contain  the  bacilli.  The 
sputum  is  by  far  the  most  important  vehicle  for  the 
conveyance  of  tubercle  bacilli  outside  the  body,  and  the 
other  excretions  are  comparatively  unimportant ;  moreover, 
the  bacilli  contained  in  the  urine  and  faeces  are  very 
quickly  destroyed  by  putrefaction.  It  is  known,  too,  that 
even  the  bacilli  in  the  sputum  may  already  have  lost  their 
virulence  (Koch  and  Kitasato),  but  this  is  not  always  the 
case,  and  it  has  been  shown  that  while  one  portion  of  a 
sputum  did  not  infect  animals  by  the  bacilli  which  it 
contained,   another  portion  of  the  same  sputum  contained 

124 


THE   PREVENTION   OF   INFECTIOUS   DISEASES 

numerous  virulent  bacilli  (Cornet).  The  sputum  of  the 
patient  should  therefore  be  made  innocuous.  Since  the 
State  and  the  district  authorities  have  turned  their  atten- 
tion to  this  branch  of  prophylaxis  a  noticeable  diminution 
of  tuberculosis  has  been  recorded  in  Germany.  Before  the 
year  1889  the  mortality  caused  by  tuberculosis  in  Prussia 
was  thirty  to  thirty-two  per  10,000  of  the  population,  now 
it  is  only  twenty- one  to  twenty- two  per  10,000  (Cornet), 
In  hospitals  and  in  sanatoria  where  there  is  adequate 
supervision  it  is  easy  to  see  that  the  sputum  is  not  ex- 
pectorated on  to  the  ground  or  into  the  handkerchief  but 
into  sputum  cups.  In  private  practice  it  can  only  be 
done  if  the  physician  ceaselessly  instructs  his  patients 
about  the  matter ;  bedridden  patients  should  have  simple 
sputum  glasses  or  cups,  into  which  a  little  water  with  or 
without  some  disinfectant  has  been  previously  poured. 
Plain  water  answers  the  purpose,  for  all  we  need  to  do 
is  to  prevent  the  sputum  from  becoming  dry  and  from 
being  scattered  as  dust  through  the  air  to  be  breathed  by 
other  human  beings.  Phthisical  patients  who  still  get 
about  should  carry  a  pocket  sputum  flask  ;  Dettweiler's 
flask  is  most  generally  used.  Unfortunately  patients  often 
fail  to  use  such  flasks  because  they  dislike  attracting 
attention  to  themselves  and  being  recognized  everywhere 
as  consumptives  by  their  use  of  a  flask,  and  this  is  only 
natural  from  the  human  standpoint.  To  do  away  with 
this  difficulty  the  use  of  flasks  should  he  made  general 
for  all  people  who  have  any  expectoration,  not  only  for 
consumptives  but  also  for  all  who  suffer  from  bronchitis, 
asthma,  or  disease  of  the  throat  or  larynx.  The  sputum 
flask  would  then  not  be  the  sign  of  a  consumptive,  but 
merely  an  indication  of  a  conventional  custom  which  dic- 
tates that  well  bred  people  expectorate  into  a  flask  instead 
of  into  a  room,  a  carriage  or  other  similar  place.  These 
flasks  can  then  be  emptied  down  the  closet,  care  being 
taken  that  none  is  splashed  about,  or  into  special  holes 
dug  in  the  ground.  The  patient  should  also  be  urged  not 
to  cough  or  to  sneeze  into  the  air  of  the  room,  but  to  hold 
a  cloth  or  a  hand  before  his  mouth  and  nose  when  cough- 

125 


THE  PREVENTION   0¥   DISEASE 

ing  or  sneezing.  Every  physician  knows  by  experience 
that  many  patients  will  cough,  towards  him  without  the 
least  concern  while  he  is  engaged  in  examining  them : 
constant  instruction  will  correct  such  carelessness  on  the 
part  of  the  patient.  Recent  methods  introduced  to  pre- 
vent the  saliva  from  being  scattered  into  the  air  when 
the  patient  speaks  have  already  been  described;  we  have 
not  yet  any  definite  knowledge  whether  germs  can  thus 
be  scattered  so  as  to  cause  infection,  at  present  there  are 
those  who  hold  Cornet's  view  about  this,  while  others  hold 
Fliigge's,  and  it  is  best  therefore  for  the  present  to  do 
justice  to  both  views  by  suitable  prophylactic  measures.  Re- 
cently too  a  disposition  has  been  shown  more  than  hitherto 
to  remove  patients  with  advanced  consumption  from  their 
families ;  their  copious  expectoration  which  swarms  with 
bacteria  is  a  very  great  danger  as  a  source  of  infection 
for  those  around  them.  Patients  in  the  early  stage  of 
consumption  often  have  no  bacilli  in  their  expectoration 
or  very  few  compared  with  the  enormous  number  present 
during  the  stage  when  there  are  cavities.  If  the  home 
circumstances  do  not  permit  of  the  patient  being  properly 
and  adequately  nursed,  every  effort  should  be  made  to  get 
him  into  a  hospital  during  the  later  stages  of  the  disease. 
Unfortunately  there  are  not  yet  sufficient  hospitals  for 
these  advanced  cases. 

The  prophylactic  measures  above  mentioned  for  making 
the  sputum  innocuous  are  those  to  be  observed  by  the 
patient,  but  the  healthy  should  on  their  part  also  observe 
precautions  to  protect  themselves  against  infection.  Ade- 
quate prophylactic  measures  are  required  from  childhood 
onwards.  Scrofulosis  which  nowadays  we  look  upon 
as  also  caused  by  tubercle  bacilli  and  which  often  is  the 
forerunner  of  other  forms  of  tuberculosis,  is  sometimes 
caused  in  childhood  simply  by  want  of  cleanliness.  Volland 
has  drawn  attention  to  this  fact :  small  children  come  into 
close  contact  with  the  ground  in  their  games  and  when  they 
learn  to  walk,  and  with  the  dust  on  the  floor.  They  after- 
wards touch  the  apertures  of  the  body  and  scratches  and 
wounds  with  their  dirty  fingers,  and  thus  readily  convey 

126 


THE  PEEVENTION   OF  INFECTIOUS  DISEASES 

tlie  tubercle  bacillus  and  other  germs  into  their  body.  The 
need  for  cleanliness  of  the  child's  hands,  fingernails  and 
face  should  be  impressed  upon  mothers  and  nurses.  The 
nursery  floor  should  be  wiped  over  once  or  twice  a  day, 
and  the  toys  should  be  kept  clean.  Very  special  care 
in  this  matter  must  be  observed  when  there  is  a  phthisical 
member  in  the  family  who  has  some  expectoration.  Further 
those  around  the  patient  should  avoid  any  unnecessary 
close  contact,  especially''  kissing  and  sleeping  together.  But 
the  fear  of  infection  should  not  be  carried  to  an  extreme 
so  as  to  wound  unnecessarily  the  patient's  feelings.  On 
the  contrary  those  who  are  afraid  should  particularly  be 
told  that  merely  to  be  in  the  vicinity  of  the  patient  is 
not  harmful  and  that  his  breath  is  free  from  danger ;  but 
the  spoon  and  fork  he  has  used  in  eating  should  not  be 
used  by  another  till  they  have  been  washed.  With  regard 
to  the  room,  special  stress  must  be  laid  upon  the  ordinary 
rules  of  hygiene,  such  as  ventilation,  wiping  the  floor  with 
a  damp  cloth,  and  the  avoidance  of  dust. 

After  the  death  of  a  consumptive  patient  at  home,  the 
linen,  bedding  and  clothes  should  be  thoroughly  disin- 
fected ;  the  walls  of  the  sick  room  should  be  freshly 
painted  or  papered,  or  the  old  paper  should  be  cleaned 
with  bread.  Until  the  sanitary  authorities  undertake 
the  disinfection  in  cases  of  tuberculosis  every  doctor 
should,  in  the  interests  of  the  survivors,  direct  the  disin- 
fecting of  the  rooms.  Opinions  differ  as  to  whether  it  is 
advisable  to  introduce  compulsory  notification  of  tuber- 
culosis, but  all  are  probably  agreed  that  after  a  case  of 
death  from  tuberculosis  disinfection  should  be  obligatory. 

To  prevent  tuberculous  infection  being  conveyed  from 
animals  to  man,  especially  by  meat  and  milk,  a  well 
organized  body  of  sanitary  inspectors  is  needed,  and  since 
the  tuberculin  test  is  now  extensively  used  by  veterin- 
ary surgeons  for  purposes  of  diagnosis,  it  is  possible 
to  remove  tuberculous  cattle  from  the  rest  and  thus 
gradually  stamp  out  the  tuberculosis  among  cattle  which 
is  now  so  prevalent.  Since  the  introduction  in  Germany 
of  the  compulsory  inspection  of  meat  in  slaughter  houses, 

127 


THE   PREVENTION   OF  DISEASE 

private  precautionary  measures  against  infection  through 
meat  are  not  generally  required  ;  on  the'  other  hand  milk 
should  be  boiled  or  sterilized  before  being  used  unless 
there  is  an  absolute  guarantee  that  the  cows  are  sound 
in  health.  Recently  market  butter  was  strongly  suspected 
of  being  the  conveyer  of  virulent  tubercle  bacilli  (Ober- 
miiller),  but  examinations  made  (Rabinovitsch)  gave  re- 
assuring results,  and  proved  that  the  bacilli  were  perfectly 
harmless  ones,  very  similar  to  tubercle  bacilli  for  which 
they  had  been  mistaken.  It  would  therefore  seem  that 
in  eating  butter  and  cheese  we  need  not  fear  infection  by 
tubercle  bacilli. 

The  prevention  of  scrofulosis  in  children  was  stated  above 
to  be  a  valuable  prophylactic  against  the  occurrence  of 
other  forms  of  tuberculosis  in  adult  life.  The  signs  of 
scrofula  may  all  have  disappeared,  except  possibly  some 
slight  swelling  of  the  cervical  glands,  and  the  individual  may 
apparently  be  in  good  health  for  years  till,  when  he  is  over 
twenty,  signs  of  apical  disease  of  the  lungs  appear.  The 
opinion  held  by  most  authorities  is  that  virulent  tubercle 
bacilli  may  be  lodged  and  encapsuled  in  the  different  parts 
of  the  body,  most  often  in  the  lymphatic  glands,  and  that 
even  after  many  years  some  exciting  cause  may  take  them 
into  the  lymph  stream  and  set  up  tuberculous  disease  of 
some  organ.  The  cervical,  bronchial  and  mesenteric  glands 
are  those  most  often  affected  ;  and  in  children  the  lymphatic 
glands  of  the  neck  are  by  far  the  most  common  seat  of 
scrofula.  And  further,  tuberculous  disease  of  a  joint  or 
bone,  tuberculous  affections  of  the  genito-urinarj'"  organs,  of 
the  skin  or  mucous  membranes,  may  after  an  apparently 
perfect  cure  and  complete  functional  recovery  give  rise 
years  afterwards  to  a  fresh  development  of  tuberculosis, 
especially  of  the  lungs.  Tuberculosis  is  apt  to  leave  small 
caseous  foci  which  contain  germs  still  capable  of  life 
(Grerhardt)  ;  these  foci  are  encapsuled  by  scar  tissue  and 
are  thereby  made  harmless  till  some  external  cause,  some 
injury,  breaks  as  it  were  the  capsule  and  causes  the  latent 
germs  to  become  active  again.     As  a  prophylactic  measure 

128 


THE   PREVENTION  OF  INFECTIOUS   DISEASES 

against  tuberculosis  in  the  adult,  it  is  necessary  there- 
fore that  scrofula  in  childhood  should  be  perfectly 
cured.  Whenever  possible  tuberculous  foci  should  be 
completely  removed  from  the  body  by  operation  ;  caseous 
lymphatic  glands  must  be  carefully  and  completely 
excised,  caries  of  bones  must  be  thoroughly  cured  by 
prolonged  treatment  with  iodoform.  Not  rarely  we  see 
children,  and  even  adults,  going  about  with  suppurating 
fistulous  openings  connected  with  different  bones,  with 
caries  of  the  petrous  bone  and  of  the  auditory  ossicles,  and 
yet  these  children  have  not  for  a  long  time  been  under 
medical  treatment.  In  connexion  with  this  subject, 
Penzoldt  has  recently  shown  how  important  it  is  in  the 
treatment  of  pulmonary  tuberculosis  to  inquire  carefully  in 
every  case  for  external  manifestations  of  tubercle  and  to 
cure  these  first.  The  gums  and  tonsils  and  the  mucous 
membrane  of  the  nose  and  throat  are  now  regarded  as  very 
important  localities  for  the  development  of  tuberculosis  of 
the  lungs.  Primary  tuberculosis  occurs  in  these  places  much 
more  often  than  was  formerly  believed,  and  thence  infection 
of  the  lungs  often  follows.  This  opinion  is  however  not 
held  by  all  authorities  :  thus  Moritz  Schmidt  considers  that 
these  affections  of  the  nose  and  throat  are  secondary  to 
pulmonary  tuberculosis,  and  only  very  rarely  primary. 

The  knowledge  of  the  frequent  connexion  between 
pulmonary  tuberculosis  and  earlier  tuberculous  afi^ections  of 
lymphatic  glands,  bones  and  other  organs,  should  make  us,  so 
far  as  prophylaxis  is  concerned,  regard  all  who  have  had 
such  affections  in  youth  as  predisposed  to  tuberculosis,  and 
they  should  take  as  much  care  to  guard  against  a  fresh 
infection  as  those  who  are  especially  predisposed  to  pul- 
monary tuberculosis.  It  is  therefore  necessary  in  prophy- 
lactic treatment  to  classify  more  carefully  the  individuals 
who,  according  to  medical  experience,  have  this  predis- 
position to  pulmonary  tuberculosis.  There  are  first  of  all 
those  who  are  hereditarily  tainted.  Modern  bacteriologists 
deny  that  this  hereditary  predisposition  has  any  important 
influence  upon  the  development  of  pulmonary  tuberculosis  ; 
but    the    experience    of    centuries    proves    the    powerful 

129  K 


THE  PREVENTION  OF  DISEASE 

influence  which  heredity  has  upon  the  development  of 
tuberculous  disease.  Bat  the  opinion  formerly  held  that 
tuberculous  infection  may  be  directly  inherited  is  not 
correct :  infection  of  the  child  by  germs  in  the  spermatozoa 
or  ovum  does  not  occur.  Direct  placental  infection  of  the 
child  when  the  mother  has  tubercular  disease  of  the  gene- 
rative organs  is  possible,  but  is  so  extremely  rare  that  we 
need  not  consider  it.  The  predisposition  alone  is  inherited  ; 
this  consists  not  only  in  the  configuration  of  the  thorax  but 
also  in  the  degree  of  functional  activity  of  the  organs,  which 
seems  to  us  to  be  generally  independent  of  their  anatomical 
structure,  and  in  the  entire  conformation  of  the  body  which 
makes  it  a  suitable  nidus  for  the  bacilU.  By  whatever 
words  we  express  this  kind  of  predisposition,  it  remains 
true  that  we  do  not  perfectly  understand  the  nature  of 
hereditary  predisposition  and  cannot  yet  refer  it  to  any 
obvious  lesion.  The  term  "  general  weakness "  has  been 
used  to  designate  it,  but  if  by  this  we  mean  general 
weakness  of  the  muscular  system  and  decrease  of  the 
functional  activity  of  the  body,  then  the  term  does  not 
cover  all  cases  of  hereditary  predisposition,  because  some 
individuals  who  are  muscularly  strong  and  active  also 
become  affected  with  tuberculosis.  A  large  number  of 
individuals  who  are  predisposed  to  tuberculosis  have  the 
so-called  "  phthisical  constitution,"  that  is  the  body  is 
obviously  of  slight  muscular  power ;  but  this  phthisical 
constitution  may  be  present  though  no  case  of  tuberculosis 
has  occurred  in  the  family.  The  chest  is  long  narrow  and 
flat,  the  intercostal  spaces  are  wide  and  deep,  the  neck  is 
long  and  thin ;  the  muscles  are  mostly  poorly  developed, 
especially  those  of  the  chest  and  back,  so  that  the  shoulder 
blades  often  stand  out  like  wings  and  the  ribs  and  clavicles 
are  very  clearly  seen.  Formerly  much  stress  was  laid  upon 
the  estimation  of  the  "  vital  capacity  "  of  the  lungs,  and  it 
was  thought  that  the  respiratory  capacity  in  individuals 
with  a  phthisical  constitution  was  so  greatly  reduced  as  to 
be  an  important  aid  to  diagnosis.  These  measurements 
have  not  proved  to  be  of  much  value  in  practice.  These 
individuals  are  also  of    pale  colour,  the  lips  and  the  con- 

130 


THE   PREVENTION   OF   INFECTIOUS   DISEASES 

junctivse  are  only  slightly  red,  they  are  light  in  weight,  and 
have  little  power  of  resistance  against  bad  weather  and  over- 
exertion. 

A  predisposition  to  tuberculosis  is  also  left  by  several 
other  diseases,  not  it  would  seem  because  of  any  special 
weakness  left  by  the  disease,  otherwise  all  weakening  dis- 
eases would  leave  such  predisposition  ;  but  rather  we  must 
assume  because  the  constitution  of  the  lymph  and  of  the 
blood  after  these  illnesses  favours  the  implantation  of  the 
tubercle  bacillus.  In  children  pulmonary  tuberculosis  often 
follows  measles  and  also  whooping  cough  ;  so  during  and 
after  these  illnesses  special  care  must  be  taken  to  guard 
such  children  against  infection  by  the  precautionary 
measures  enumerated  above,  and  above  all  by  cleanliness  of 
their  hands,  faces  and  surroundings.  Syphilis  in  children 
and  in  adults  increases  the  predisposition  to  tuberculosis, 
so  too  possibly  does  influenza;  and  according  to  Jiirgensen, 
also  catarrhal  pneumonia.  After  catarrhal  pneumonia  it  is 
most  essential  to  develop  the  respiratory  muscles  and  to 
order  a  long  stay  in  the  country.  Those  suffering  from 
diabetes  are  specially  prone  to  develop  tuberculosis.  Just  as 
colonies  of  tubercle  bacilli  flourish  more  luxuriantly  in  a 
nutritive  medium  containing  sugar,  so  too  the  growth  of 
the  bacilli  in  the  human  body  seems  to  be  favoured  by  an 
increased  amount  of  sugar  in  the  lymph  and  blood  ;  one 
fourth  of  those  who  suffer  from  diabetes  are  said  to  die  of 
phthisis  (Gr.  See). 

In  another  way  certain  other  affections  may  also  increase 
the  predisposition  to  tuberculosis  by  reducing  the  power  of 
resistance  of  the  epithelium,  for  instance  abrasions  afford  a 
passage  for  the  infection.  To  this  category  belong  the 
catarrhs  of  the  upper  respiratory  passages,  especially 
chronic  bronchitis  and  pharyngitis  and  laryngitis.  Also 
inability  to  breathe  through  the  nose  by  reason  of  swollen 
turbinates  or  adenoid  vegetations,  so  that  the  air  fails  to  be 
filtered  by  passing  through  the  nose.  And  further  certain 
occupations  predispose  to  tuberculosis  because  the  inhalation 
of  sharp  particles  causes  lesions  in  the  bronchial  mucous  mem- 
brane ;  for  example  the  occupation  of  workers  in  stone,  glass 

131 


THE  PREVENTION   OE   DISEASE 

grinders  and  file  cutters.  Infection  will  then  readily  occur 
through  intercourse  with  phthisical  patients  or  through  a 
prolonged  stay  in  crowded  rooms  where  phthisical  patients 
have  expectorated. 

All  individuals  belonging  to  these  classes  with  a  special 
predisposition  to  pulmonary  tuberculosis  need  regular  and 
thorough  preventive  treatment  as  a  prophylaxis  against 
infection  as  detailed  above.  But  they  must  also  be  guarded 
against  all  injurious  influences  which  tend  to  lower  the 
resisting  power  of  the  body.  The  patient  often  tells  the 
physician  that  the  illness  began  after  a  cold,  after  some 
over-exertion,  or  after  some  accident.  Medical  observation 
has  shown  that  such  accidental  causes  not  rarely 
determine  the  outbreak  of  tuberculosis,  especially  when 
predisposition  to  it  is  present.  Among  these  accidental 
causes  are  colds,  injuries,  physical  and  mental  over-exertion, 
mental  depression,  alcoholic  and  venereal  excesses.  The 
tendency  to  taking  cold  must  be  combated  by  regular 
methodical  treatment  which  hardens  the  body,  and  the 
individual's  occupation  and  mode  of  life  should  be  so  far  as 
possible  such  as  to  prevent  exposing  the  body  and  mind  to 
great  changes  of  condition.  Every  kind  of  excess  must  be 
absolutely  forbidden  to  such  patients ;  no  alcohol  should  be 
allowed  except  a  little  beer  or  wine,  no  tobacco,  and  modera- 
tion in  sexual  intercourse  should  be  enjoined.  Measures 
should  be  adopted  to  improve  the  general  condition  of  the 
body  and  thus  at  the  same  time  reduce  the  predisposition  to 
the  disease.  Great  care  is  required  in  the  matter  of  diet : 
thin  and  weak  individuals  should  have  good  and  appropriate 
food  to  increase  their  body  weight ;  they  should  have  fresh 
air  in  their  rooms  and  be  much  out  in  the  open  air. 
Breathing  exercises  should  be  regularly  practised  out  of 
doors — deep  inspiration. and  expiration  with  intervals,  the 
chest  being  free.  Moderate  exercise  also,  according  to  the 
state  of  each  individual,  should  be  taken,  and  possibly 
moderate  exercise  on  horseback.  In  bad  weather  the 
exercises  should  be  performed  indoors  with  open  windows. 

If  it  is  conceded  that  tuberculosis  generally  attacks  the 
apex  of  the  lung  because  the  respiration  and  the  circulation 

132 


THE   PREVENTION   OE   INEECTIOUS   DISEASES 

are  less  vigorous  at  the  apex  than  in  the  rest  of  the  Inng, 
then  it  is  important  in  prophylactic  treatment  to  see  that 
the  apices  of  the  lungs  are  well  ventilated  by  deep  inspira- 
tion while  the  shoulders  are  kept  low.  So  often  one  sees 
young  people  during  their  growth  in  a  faulty  attitude,  with 
the  head  and  neck  bent  forward  and  the  shoulders  high ; 
this  position  interferes  more  or  less  with  respiration  at  the 
apices  of  the  lungs,  and  special  attention  should  therefore 
be  given  to  the  attitude.  The  preventive  measures  with 
regard  to  the  care  of  the  body  and  mind  are  similar  to  those 
required  in  the  treatment  of  tuberculosis. 

Authorities  rightly  insist  upon  the  necessity  of  preventive 
treatment  of  tuberculosis,  and  the  physician  ought  not  to  wait 
until  he  discovers  an  impaired  note  at  the  apex  of  the  lung, 
or  hears  rales,  or  till  the  discovery  of  tubercle  bacilli  with 
the  microscope  makes  the  suspected  diagnosis  of  tuberculosis 
a  certainty,  before  he  begins  to  treat  the  patient  hygien- 
ically  and  dietetically.  Hygiene  and  diet  are  nowhere  so 
important  as  in  these  pale  thin  youths  and  young  girls  with 
shallow  respiration,  whose  poor  appetite  and  small  amount 
of  strength  are  a  constant  source  of  anxiety  to  their  friends, 
especially  when  there  is  consumption  in  the  family.  These 
individuals  must  not  be  sent  away  by  the  physician,  the 
anxious  parents  merely  being  told  that  there  is  nothing 
absolutely  wrong  with  the  lungs  and  that  there  is  no  need 
for  anxiety.  Although  the  lungs  are  not  yet  attacked, 
the  friends  should  be  urged  to  do  everything  possible  to 
strengthen  the  weak  body  and  make  it  more  capable  of 
resisting  disease.  The  public  fully  understand  and  appre- 
ciate the  endeavours  of  the  physician  to  guard  against  the 
disease.  The  prophylaxis  of  tuberculosis  is  closely  related 
to  early  diagnosis,  and  early  diagnosis  is  included  in 
prophylaxis.  We  are  not  now  referring  to  symptoms  of 
catarrh  at  the  apices,  haemoptysis,  progressive  loss  of  flesh, 
night  sweats,  fever,  which  even  when  no  bacilli  are  found 
in  the  sputum  often  sufS.ce  for  the  diagnosis ;  we  are 
referring  rather  to  other  symptoms  which  make  us  suspect 
commencing  phthisis  though  there  is  no  evident  disease  at 
the  apices  and  which  should  cause  us  to  prescribe  prophy- 

133 


THE  PREVENTION  OF  DISEASE 

lactic,  hygienic  and  dietetic  treatment.  These  symptoms 
are  general  ones  and  do  not  specially  point  to  any  local 
disease  of  the  lungs.  Thus  in  commencing  phthisis,  long- 
before  any  certain  signs  of  the  disease  appear,  we  may  find 
persistent  derangement  of  the  gastric  functions,  loss  of 
appetite,  a  feeling  of  satiety  after  having  taken  only  very  little 
food,  pain  after  eating,  in  general  the  symptoms  of  nervous 
dyspepsia  which  when  they  appear  at  an  early  age  in  one 
predisposed  to  tuberculosis  by  heredity  or  by  his  bodily 
constitution,  should  always  draw  the  physician's  attention 
to  the  lungs.  On  the  other  hand  when  there  is  a  good 
appetite  and  good  digestion,  and  yet  in  spite  of  rest  and  care 
the  patient  does  not  put  on  weight  but  even  loses  weight, 
suspicion  of  phthisis  should  again  be  aroused.  Cardiac 
disturbance  may  at  the  same  time  be  present :  there  may 
be  increased  frequency  of  the  heart's  beat  even  when  the 
patient  is  at  rest,  there  may  be  palpitation,  or  the  patient 
gets  quickly  tired  from  running  or  going  upstairs,  there  is 
a  feeling  of  lassitude,  decrease  of  muscular  power  and 
disinclination  to  activity.  The  heart  is  often  irritable,  and 
slight  muscular  exertion  or  ordinary  mental  influences  at 
once  cause  great  increase  of  the  heart's  action  with  a  small 
weak  pulse.  The  apex  beat  often  extends  farther  to  the 
right  or  left  than  is  usual,  it  is  strong  and  forcible,  and 
contrasts  with  the  weak  pulse.  In  the  early  diagnosis  of 
tuberculosis  note  must  be  taken  too  of  recurrent  attacks  of 
hoarseness  which  quickly  pass  away  ;  no  change  can  as  a 
rule  be  detected  by  the  laryngoscope,  it  seems  to  be  due  to 
purely  nervous  influences.  In  other  cases  a  true  catarrh  of 
the  larynx  and  pharynx  which  is  very  obstinate  and 
readily  recurs  is  the  initial  symptom  of  pulmonary  tuber- 
culosis. These  signs  have  nothing  to  do  with  genuine 
laryngeal  tuberculosis,  and  this  is  also  true  of  the  peculiar 
anaemic  condition  of  the  laryngeal  mucous  membrane, 
especially  noticeable  near  the  epiglottis ;  this  striking 
degree  of  pallor  is  said  to  be  caused  by  atrophy  of  the 
mucous  membrane  which  makes  the  muscles  of  the  larynx 
unusually  prominent  (Roe).  Many  regard  this  anaemic 
condition  of  the  larjaix  as  of  early  diagnostic  value. 

134 


THE  PREVENTION   OF  INEECTIOUS  DISEASES 

In  very  doubtful  cases  use  may  be  made  of  the  tuber- 
culin test  to  establish  an  early  diagnosis,  but  though,  this 
method  has  been  highly  recommended  it  has  not  yet  been 
introduced  into  practice,  probably  because  it  requires  care- 
ful observation  of  the  patient  during  several  days  such  as 
is  generally  possible  only  in  a  hospital.  For  two  days 
before  the  inoculation  the  patient's  temperature  should  be 
taken  regularly  every  two  hours,  in  order  to  ascertain  what 
is  the  normal  condition.  The  patient  is  then  inoculated 
with  one  milligram  of  tuberculin.  Most  are  agreed  that 
the  old  tuberculin  is  preferable  to  the  new.  After  inocula- 
tion the  temperature  is  again  taken  every  two  hours,  and 
reaction  usually  appears  eight  to  sixteen  hours  after  inocu- 
lation. If  there  is  no  reaction  the  patient  should  be 
inoculated  a  few  days  later  with  three  milligrams  of  tuber- 
culin, and  if  necessary  again  later  with  six  milligrams. 
If  there  is  still  no  reaction  we  may  be  tolerably  certain 
that  there  is  no  tuberculosis  (Cornet).  In  some  cases,  even 
though  there  is  no  rise  of  temperature,  inoculation  helps  us 
to  make  a  diagnosis,  because  catarrhal  signs  at  the  lung 
apices  become  manifest,  owing  to  increased  exudation  at  the 
places  where  tuberculous  processes  are  going  on.  Moreover 
when  there  is  a  positive  febrile  reaction,  it  does  not  neces- 
sarily point  to  a  diagnosis  of  pulmonary  tuberculosis,  but 
only  to  the  presence  of  a  tuberculous  focus  somewhere  in 
the  body. 

The  question  of  marriage  of  tuberculous  patients  about 
which  the  physician  is  often  consulted,  is  of  special 
significance  in  connection  with  prophylaxis.  The  question 
as  regards  the  effect  upon  any  offspring  of  the  marriage 
may  be  put  altogether  on  one  side,  as  it  is  probably  never 
taken  into  consideration  by  those  who  want  to  marry.  We 
need  consider  only  the  tuberculous  partner  in  the  marriage 
and  the  healthy  one.  If  the  disease  has  existed  for  a  long 
time  and  is  progressing  the  physician  will  absokitely  forbid 
marriage,  not  only  for  social  reasons  but  also  because 
experience  proves  that  such  patients  get  rapidly  worse  after 
marriage. 

In  the  initial  stage  of  pulmonary  tuberculosis,  no  general 

136 


THE  PREVENTION   OF  DISEASE 

rules  can  be  laid  down  as  to  giving  medical  permission 
to  marry.  It  is  wisest  in  all  sucli  cases  first  to  try  to 
cure  the  disease  ;  and  this  is  best  done  by  placing  the  tuber- 
culous patient  in  a  sanatorium  for  consumptives.  A  patient 
who  is  so  far  improved  that  he  has  had  no  pulmonary  signs 
for  two  years  and  who  is  in  a  good  state  of  nutrition  may  be 
allowed  to  marry.  Medical  experience  has  shown  that  a 
phthisical  woman  is  exposed  to  great  dangers  by  marriage  ; 
pregnancy  and  parturition  often  cause  very  rapid  aggrava- 
tion of  the  disease.  The  physician  must  therefore  be  even 
more  careful  in  granting  consent  to  marriage  to  a  tubercu- 
lous woman  than  to  a  tuberculous  man,  and  should  never 
give  it  till  he  has  first  tried  to  cure  the  disease.  For  the 
sake  of  the  healthy  one  too,  the  physician  should  withhold 
consent  to  marriage  with  a  phthisical  person.  Cornet's  sta- 
tistics show  that  double  tuberculosis  in  marriage  occurs  in 
twenty-three  per  cent,  of  the  cases,  and  though  we  cannot 
in  all  the  twenty- three  per  cent,  attribute  the  double  tuber- 
culosis to  infection  of  the  sound  partner  in  married  life  by 
the  diseased  partner,  yet  a  number  of  medical  observations 
leave  no  doubt  that  infection  through  marriage  is  possible. 
Those  who  wish  to  marry  should  be  told  of  this  danger  by 
the  physician. 


136 


The  Prevention  of  the  Diseases  of  the 
Lungs 

By   dr.  RICHARD   ROSEN 


137 


The  Prevention  of  the  Diseases  of  the 

Lungs 

The  consideration  of  tlie  prophylaxis  of  the  diseases  of  the 
lungs,  of  the  heart  and  of  other  organs  separately  is  not  in 
accord  with  the  division  into  "infective  diseases"  and 
"  constitutional  diseases."  It  is  merely  the  old  method  of 
grouping  diseases  according  to  the  organ  affected,  and  may 
be  retained  as  useful  in  describing  the  prophylactic  treat- 
ment, though  not  in  accord  either  with  aetiology  or  path- 
ology. For  example,  in  bronchitis  the  invasion  by  bacteria 
is  no  less  important  as  regards  aetiology  than  it  is  in 
"infective  disease" ;  it  is  moreover  no  purely  "  local"  disease, 
but  nearly  always  has  general  symptoms,  as  does  an 
"  infective  disease."  Nevertheless  in  bronchitis  and  other 
affections  classed  as  "  pulmonary  diseases,"  the  local  dis- 
turbances are  upon  the  whole  by  far  the  most  important 
symptoms,  and  the  old  classification  is  therefore  justified. 
For  the  prophylaxis  of  pulmonary  diseases,  external 
injurious  influences  must  be  avoided  and  attention  must 
obviously  be  given  to  the  condition  of  the  air,  because  it  is 
the  element  which  comes  most  closely  into  contact  with  the 
lungs,  and  because  meteorological  changes  react  upon  the 
lungs.  Indeed  from  time  immemorial  the  instincts  of  the 
people  have  caused  them  to  attach  great  importance  to 
changes  in  the  weather  in  the  causation  of  pulmonary 
disease.  The  effect  of  air  upon  the  lung  is  twofold :  first, 
there  is  a  direct  effect  depending  upon  respiration ;  but  the 
breathing  of  air  under  varying  conditions  is  not  the  chief 
causative  factor  of  disease,  because  before  it  actually 
reaches  the  lung  it  has  been  modified  by  the  natural 
protective     processes.        Indirectly    however    atmospheric 

139 


THE   PREVENTION   OF   DISEASE 

changes  do  cause  disease  of  the  lungs,  through  their  action 
upon  the  skin.  In  former  times  cold  was  stated  to  be  the 
cause  of  disease  in  far  too  great  a  number  of  cases,  and 
further  knowledge  has  shown  that  many  diseases  formerly- 
attributed  to  cold  owe  their  origin  to  bacterial  infection. 
But  in  diseases  of  the  air  passages  cold  has  maintained  its 
footing  and  is  considered  of  importance  aetiologically ;  and 
it  makes  no  real  difference  that  bacteria  assist  the  cold  in 
the  production  of  the  disease. 

The  many  theories  about  the  nature  of  a  "cold"  (Rosen- 
thal, Lode,  etc.)  none  of  which  adequately  explains  the 
phenomena,  will  not  here  be  further  discussed.  It  seems 
however  to  be  certain  that  chilling  of  a  large  surface  of  the 
body  is  not  always  necessary  for  a  cold,  but  that  the  cold 
may  be  caused  reflexly :  a  very  brief  action  of  cold  upon  a 
limited  part  of  the  body  will  reflexly  produce  very  con- 
siderable changes  in  the  distribution  of  blood  to  the  internal 
organs,  which  may  lead  to  circulatory  obstruction  at 
definite  spots.  This  hyperaemia  is  a  factor  which 
makes  disease  possible.  We  may  assume  that  there  is 
then  diminished  power  of  resistance  in  the  cells  which 
enables  bacteria  to  get  into  the  tissues ;  but  the  whole 
process  is  not  made  more  intelligible  to  us  by  this  assump- 
tion. In  different  individuals  again  the  locus  minoris 
resistentiae  is  different ;  in  some  cases  it  is  always  one 
and  the  same  spot  which  becomes  affected  by  the  same 
injurious  influence,  a  cold.  Experience  shows  that  getting 
wet  through  often  causes  a  cold,  especially  when  the  body 
does  not  continue  in  activity.  A  cold  may  also  be  caused  by 
sudden  changes  of  temperature,  whether  an  atmospheric 
change — for  instance  after  sunset  at  the  seaside  in  the 
height  of  summer — or  a  change  through  going  out  of  a 
heated  house  in  the  winter  without  sufficient  clothing. 
Damp  cold  abstracts  even  greater  heat  from  the  body  and  is 
particularly  liable  to  give  a  cold,  and  since  in  our  latitude 
the  transition  months  from  winter  to  summer  and  summer 
to  winter  are  accompanied  by  many  changes  in  temperature 
and  moisture,  diseases  caused  by  cold  are  very  common  at 
these  times,  as  is  proved  by  many  statistics. 

140 


THE   PREVENTION   OF   DISEASES   OF   THE   LUNOS 

In  Germany  the  commonest  locus  minoris  resistentiae  for 
colds  is  the  mucous  membrane  of  the  air  passages,  and  there- 
fore catarrhs  of  the  bronchi  and  of  the  trachea  are  very 
common  diseases.  The  predisposition  to  bronchitis  is  general, 
even  robust  natures  are  not  free  from  it,  although  usually 
weak  anaemic  people  are  more  susceptible  to  it  (Riegel), 
Bronchitis  is  apt  to  appear  at  every  period  of  life,  though 
the  mortality  is  particularly  great  in  childhood. 

Bronchitis  is  so  common  that  prophylactic  measures  are 
indicated  for  all,  particularly  when  we  remember  that  a 
large  number  of  pulmonary  diseases  are  often  the  result  of 
bronchitis — not  only  chronic  forms  of  bronchitis,  but  also 
emphysema,  catarrhal  pneumonia,  capillary  bronchitis, 
pulmonary  collapse,  and  lastly  though  not  so  obviously 
bronchial  asthma.  It  follows  therefore  that  the  prevention 
of  bronchitis  is  at  the  same  time  the  prevention  of  a  large 
number  of  other  pulmonary  diseases,  and  to  a  certain 
extent  also  of  pulmonary  tuberculosis. 

Geigel  was  the  first  to  point  out  that  during  the  first 
year  of  life  more  legitimate  children  die  of  respiratory 
diseases  than  illegitimate  children,  though  the  converse  is 
true  for  deaths  from  digestive  troubles  ;  and  he  explains 
it  by  the  fact  of  the  greater  coddling  of  legitimate 
children.  Many  objections  may  be  raised  to  Greigel's  con- 
clusion, yet  it  is  supported  by  the  fact  known  to  all,  that 
coddhng  often  leads  to  bronchitis  and  to  other  diseases  as 
a  consequence  of  taking  cold,  and  that  bracing  the  skin  is 
the  best  protection  against  taking  cold,  and  therefore  also 
against  bronchitis,  which  is  the  most  common  result  of  the 
cold.  Children  in  their  first  year  of  life  and  very  old  people 
may,  to  a  great  extent,  be  directly  protected  against  such 
injurious  influences  if  they  remain  in  warm  ventilated 
rooms  when  the  weather  is  bad,  or  very  windy,  or  damp 
and  cold.  With  most  people  such  prophylactic  measures 
are  naturally  not  practicable,  they  are  obliged  to  go  out  in 
all  weathers.  Those  who  are  able  to  take  such  precautions 
and  who  know  by  experience  that  a  particular  state  of  the 
weather  readily  gives  them  cold,  should  be  urged  to  guard 
against  such  direct  influences  so  far  as  possible.      Others 

141 


THE  PREVENTION  OF  DISEASE 

must  be  directed  to  wear  suitable  clothing  according  to  the 
weather  and  the  principles  of  hygiene. 

Recently  dress  material  has  been  manufactured  which  is 
impregnated  with  substances  to  make  it  waterproof,  but 
the  impermeable  material  causes  a  retention  of  vapours 
given  off  by  the  skin,  which  is  disagreeable  and  will 
prevent  this  material  from  being  extensively  used. 

For  the  large  majority  therefore  the  most  valuable 
preventive  measure  against  bronchitis  is  to  harden  the  skin, 
that  is  to  accustom  it  to  the  most  diverse  conditions  of  the 
weather.  Through  his  dress  and  by  constant  living  in  rooms, 
the  civilized  man  seems  to  have  lost  the  power  which  his 
skin  possessed,  in  common  with  that  of  animals  and  of 
uncivilized  races,  of  reacting  promptly  to  the  various 
changes  of  temperature  by  different  degrees  of  contraction. 
This  function  of  the  skin  is  merely  a  question  of  practice, 
in  the  same  way  as  the  functional  activity  of  all  other 
organs  is  brought  about  in  response  to  various  demands 
made  upon  them.  For  this  reason  the  countryman  is  upon 
the  whole  more  robust  than  the  town  dweller  ;  the  country- 
man's skin  is  exercised  from  his  youth  and  is  therefore  har- 
dened and  needs  no  special  artificial  methods.  The  town 
dweller  on  the  other  hand  gets  too  little  away  from  the 
even  temperature  of  his  room,  and  the  streets  moderate 
considerably  the  power  of  the  wind.  Yet  an  atmosphere 
which  is  in  movement  deprives  the  body  of  more  heat  than 
a  calm  atmosphere,  even  though  the  latter  be  colder.  The 
town  dweller  gives  his  skin  too  little  practice  as  an  organ 
which  regulates  the  heat  of  the  body,  and  if  he  exposes 
himself  to  any  great  change  of  atmosphere,  to  a  wetting  or 
similar  influence,  the  compensatory  activity  of  the  skin 
fails  him. 

For  this  reason  the  skin  should  not  from  the  very 
earliest  years  be  too  anxiously  protected  from  coming  into 
direct  contact  with  the  atmosphere;  the  dress  should  be 
porous  and  not  too  much  in  quantity.  Lately  more 
attention  has  been  given  to  the  matter,  and  it  is  taught 
that  children  should,  from  their  earliest  youth,  not  be  kept 
too  warm  ;  that  binders  should  not  be  used,  that  bed  cover- 

142 


THE   PREVENTION   OE  DISEASES   OF   THE  LUNGS 

ing  in  the  summer  should  be  simple,  a  blanket  and  sheet, 
and  in  the  winter  a  moderately  thick  eider-down  quilt ; 
and  the  child  should  not  lie  upon  a  feather  bed.  The 
bedding  of  adults  is  liable  in  general  to  be  far  too  much, 
and  so  too  the  clothes  they  wear.  A  physician  has  many 
opportunities  for  observing  this.  No  small  number  of  men 
wear  a  woollen  vest  under  the  linen  shirt  in  summer,  much 
the  same  indeed  as  they  wear  in  winter,  and  they  wear  it 
for  fear  of  catching  cold.  Indeed  they  would  take  cold  if 
one  day  they  suddenly  altered  their  habit  and  left  off  the 
woollen  vest.  Through  coddling  their  skin  has  lost  its  com- 
pensatory power.  This  is  not  the  place  to  discuss  in  full 
the  question  of  dress,  and  we  shall  merely  point  out  the 
necessity  of  avoiding  from  youth  up  the  wearing  of  too 
many  clothes.  In  the  summer  linen  underclothing  and  a 
light  woollen  or  cotton  suit  over  this  is  sufficient ;  in  the 
winter  a  thicker  under  garment  should  be  substituted,  or 
perhaps  two  thinner  ones.  It  is  impossible  to  give  rules  for 
dress  which  are  suitable  for  all.  Weak  anaemic  people  require 
more  clothes  than  the  robust.  The  one-sided  "  dress 
systems"  advocated  by  some  apostles  of  health  are  not  based 
upon  scientific  principles,  nor  are  they  of  practical  value  for 
all.  It  is  important  that  physicians  should  concern 
themselves  more  with  the  dress  of  patients  and  its  suit- 
ability. G-reat  mistakes  are  made  about  clothing,  and  it  is 
most  essential  that  a  beginning  should  be  made  in  the  very 
earliest  years  to  strengthen  the  skin. 

With  clothes  we  introduce  something  which  is  artificial 
into  the  domain  of  nature,  and  the  natural  function  of  the 
skin  is  restricted  from  the  very  outset.  To  remove  the 
effect  of  this  disturbing  element  in  the  economy  of  nature, 
it  is  desirable  to  use  some  counter-effect  upon  the  skin  and 
to  subject  it  systematically  to  the  stimulus  of  cold  for  brief 
periods,  and  cold  water  is  best  adapted  for  this  purpose. 
Cold  water  produces  a  powerful  contraction  of  the  cutaneous 
vessels,  and  when  afterwards  the  skin  is  well  rubbed  or  the 
body  is  exercised,  the  vessels  dilate  and  a  feeling  of  well- 
being  and  of  warmth  pervades  the  whole  body.  This  cold 
water  procedure  should  bo  gone  through  daily,  best  in  the 

143 


THE  PREVENTION   OF  DISEASE 

morning  after  getting  up,  and  should  be  commenced  in  the 
first  year  of  life.  In  this  way  the  activity  of  the  skin  is 
stimulated,  and  it  reacts  promptly  to  the  stimuli  of  changes 
of  temperature  to  which  it  may  be  exposed.  If  children 
are  fairly  strong,  one  may  begin  a  few  weeks  after  birth, 
and  pour  cool  water  over  them  after  the  daily  warm  bath. 
Children  are  generally  bathed  in  water  which  is  much  too 
hot :  the  bath  water  should  never  be  above  95°  F.  A  bath 
thermometer  is  too  seldom  used  in  the  nursery :  the  heat  of 
the  water  is  judged  by  the  hand  or  the  elbow,  and  the  result 
is  that  the  temperature  is  frequently  too  high.  A  differ- 
ence of  only  two  degrees  in  the  heat  of  the  bath  water  will 
make  a  very  great  difference  in  the  effect  of  the  bath  upon 
the  body.  Baths  at  a  higher  temperature  than  95°  F 
generally  stimulate  strongly  and  are  followed  by  exhaustion, 
and  should  therefore  as  a  rule  be  avoided.  After  the  first 
months  the  bath  temperature  is  gradually  reduced  for 
children  from  95°  F  to  93°  and  90°  F  ;  the  bath  should  not 
last  longer  than  five  or  ten  minutes.  After  the  bath  cooler 
water  should  be  poured  over  the  child  and  the  skin  be  well- 
rubbed.  Later,  in  place  of  the  daily  bath,  the  whole  body 
should  be  rubbed  down  daily  with  a  rough  towel  dipped  in 
•cold  water  and  then  rubbed  dry.  Warm  baths  with  the 
addition  of  aromatic  substances,  and  brine  baths,  are  no 
longer  so  much  in  vogue  for  children  as  formerly ;  the 
increased  metabolism  which  one  hoped  to  bring  about  in 
anaemic  and  scrofulous  conditions  often  did  not  appear. 
Rubbing  down  with  water,  gradually  colder  and  colder,  is 
now  preferred  (Heubner),  as  its  stimulating  effect  is  found 
to  be  greater.  Lukewarm  brine  baths  of  short  duration,  at 
intervals  of  a  few  days,  may  be  used  with  advantage,  but 
should  always  be  followed  by  the  pouring  of  cold  water 
over  the  body. 

If  a  commencement  has  thus  been  made  in  early  youth 
in  hardening  the  body,  cold  water  applications  will  be  well 
borne  all  through  the  year  and  should  be  daily  practised 
even  in  winter — cold  rubbing  down  of  the  whole  body,  cold 
douches,  cold  baths,  or  possibly  only  cold  sponging  one  part  of 
the  body.     In  his  Recollections  of  an  Old  Physician^  Kuss- 

144 


THE   PREVENTION  OF  DISEASES  OF  THE  LUNGS 

maul  narrates  in  a  most  interesting  manner  how  as  a  young 
country  practitioner  he  suffered  much  from  colds,  and  how 
he  made  his  body,  which  was  weak  and  very  sensitive  to 
changes  of  the  weather,  quite  weatherproof  by  washing  his 
feet  with  cold  water  every  evening  shortly  before  going  to 
bed  ;  and  from  that  time  till  the  present  he  has  never  had 
a  cold. 

This  shows  that  even  when  measures  to  harden  the  body 
have  been  neglected  in  youth,  it  is  still  possible  later  and  in 
adult  life  to  harden  the  body  by  the  action  of  cold  water, 
but  it  must  then  be  undertaken  with  greater  caution,  must 
not  be  begun  in  winter,  and  the  measures  must  not  be  too 
vigorous  and  the  water  not  too  cold  at  first. 

There  are  people  who  are  particularly  susceptible  to  a 
chilling  of  some  one  part  of  the  body,  who  cannot  go  out  of 
doors  with  the  head  uncovered  without  taking  cold,  and 
who  have  always  to  wear  a  neckerchief,  or  chest  protector, 
or  abdominal  belt,  or  mittens,  or  gaiters,  to  keep  themselves 
in  good  health.  All  these  are  coddling  ways  which  could 
generally  be  done  away  with  if  the  body  were  properly 
hardened.  Moritz  Schmidt  says  it  is  astonishing  to  see  how 
many  people  coddle  and  weaken  their  bodies  in  the  most 
terrible  way,  although  they  know  and  see  the  obvious 
advantages  possessed  by  one  who  is  robust ;  it  is  probably 
because  the  sensation  of  warmth  is  pleasanter  than  that  of 
cold  ;  but  when  once  the  body  is  hardened  the  cold  will  no 
longer  be  felt  to  be  unpleasant. 

However  there  are  individuals  who  have  some  real 
locus  minoris  resistentiae  and  who  would  at  once  become  ill  if 
they  neglected  the  ordinary  precautions  they  have  been 
accustomed  to  take.  This  must  be  specially  considered  in 
the  case  of  old  people,  and  it  would  be  altogether  wrong  to 
proceed  with  measures  to  harden  the  body  regardless  of  this. 
In  such  case  the  wearing  of  flannel  next  the  skin  is  a  good 
protection  against  changes  of  temperature,  and  it  may  be  a 
flannel  under-garment  covering  the  whole  body,  or  a  flannel 
binder,  cloth  or  wrap  to  be  applied  to  that  part  which  is 
known  to  be  specially  susceptible.  The  feet  are  often  the 
most  susceptible  parts,  as  they  are  farthest  from  the  heart 

145  L 


THE  PEEVENTION  OF  DISEASE 

and  the  circulation  there  is  most  feeble.  Many  people  suffer 
constantly  from  cold  feet  which  are  either  moist  or  dry ; 
and  these  cold  feet  are  often  a  cause  of  bronchitis  which  in 
such  cases  soon  becomes  chronic  and  will  not  be  cured  till 
the  original  cause  has  been  removed.  We  have  known 
many  chronic  irritative  conditions  of  the  tracheal  and 
bronchial  mucous  membrane  cured  by  simple  directions 
about  changing  the  stockings  once  or  twice  a  day, 
and  proper  care  of  the  feet,  by  means  of  baths  and  rubbing 
with  a  spirit  lotion  and  so  on.  All  physicians  know  how 
negligent  and  careless  about  their  body  the  large  number  of 
people  are,  and  that  a  doctor  has  to  ask  searching  questions 
about  all  the  details  of  the  bodily  functions ;  till  then  a 
patient  often  does  not  know  that  some  part  of  his  body  is 
not  acting  normally,  because  he  has  no  pain.  And  often  he 
has  not  noticed  that  his  feet  are  damp  and  cold  until  the 
doctor  puts  the  question  to  him.  One  should  not  neglect  to 
advise  weak  and  susceptible  persons  to  be  careful  to  wear 
galoshes  in  rainy  weather ;  often  too  it  is  useful  to  wear 
soles  inside  the  boots,  which  are  made  of  some  material  that 
is  not  a  good  conductor  of  heat. 

The  air  in  inspiration  is  brought  into  direct  contact  with 
the  air  passages,  and  faulty  physical  or  chemical  conditions 
of  the  atmosphere  may  cause  disease :  for  the  prophylaxis  of 
these  diseases  the  condition  of  the  air  inspired  must  be 
normal.  This  subject  is  really  a  part  of  general  hygiene  : 
it  is  concerned  with  the  methods  for  regulating  the  con- 
dition of  the  air  in  rooms ;  the  removal  of  certain  gases  and 
vapours  generated  in  various  industries,  which  if  breathed 
would  lead  to  severe  acute  or  chronic  pulmonary  affections  ; 
the  prevention  of  excessive  quantities  of  dust  in  the  air  of 
workshops,  which  in  the  case  of  mineral  dust  would 
gradually  lead  to  extensive  injuries  of  the  pulmonary  tissue 
— for  instance  siderosis  and  chalicosis;  and  the  measures 
which  would  protect  the  workmen  against  the  dust. 

The  nose  is  a  natural  protection  against  the  usual 
oscillations  in  the  condition  of  the  air,  variations  in  tem- 
perature and  amount  of  moisture  and  dust ;  and  it  is  most 
essential  in  the  prophylaxis  of  diseases  of  the  lungs   that 

146 


THE  PREVENTION   OE   DISEASES   OF   THE  LUNGS 

this  nasal  function  be  normal.  The  nose  in  its  natural 
condition  has  an  important  function  to  perform  in  respira- 
tion, and  deviations  from  the  normal  condition  soon  lead  to 
diseases  of  the  air  passages. 

Normally  the  nose  prepares  as  it  were  the  air  for  the 
lungs,  saturates  the  air  with  moisture — at  least  this  is  the 
view  held  by  most  authorities — and  warms  it  almost  to  the 
temperature  of  the  body.  Aschenbrand  and  Bloch  found 
that  the  air  was  warmed  up  to  86°  F.  whatever  the 
temperature  of  or  amount  of  moisture  in  the  external  air. 
Normally  too  the  nose  removes  all  impurities  from  the  air, 
retaining  dust  and  micro-organisms  on  the  moist  mucous 
membrane  of  the  meatus  ;  and  some  are  prevented  from 
entering  by  the  vibrissse  at  the  nostrils.  Abnormal  internal 
conditions  will  be  occasioned  by  any  deviations  from  the 
normal  of  the  air  which  has  reached  the  lower  part  of  the 
respiratory  tract.  Obstruction  of  the  nasal  passages  by 
polypi,  swelling  of  the  turbinates,  adenoid  growths  and 
similar  affections  will  more  or  less  limit  nasal  respiration, 
and  oral  respiration  becomes  necessary.  But  oral  respiration 
cannot  permanently  take  the  place  of  nasal  respiration 
because  the  mucous  membrane  of  the  mouth  and  throat  soon 
gets  dry,  as  everyone  knows  who  has  had  to  breathe  through 
his  mouth  when  suffering  from  a  nasal  catarrh,  particularly 
in  a  dry  heated  room.  After  tracheotomy  too  the  air  has 
to  be  kept  permanently  moist  by  artificial  means.  Dust 
and  other  injurious  particles  are  not  filtered  from  the  air  by 
oral  respiration,  and  for  this  reason  the  trachea  and  bronchi 
soon  become  affected.  Though  there  is  no  obstruction  to 
the  passage  of  the  air  through  the  nasal  cavity,  yet  if  the 
mucous  membrane  of  the  nose  is  affected  and  unable  to 
perform  its  normal  function  of  preparing  the  air,  especi- 
ally in  chronic  atrophic  conditions  of  the  membrane,  the  air 
is  then  not  properly  prepared  and  reaches  the  deeper  air 
passages  in  too  dry  a  state,  and  the  result  is  again  bronchitis. 
The  normal  nasal  mucous  membrane  alone  has  the  mar- 
vellous capacity  of  compensating  for  differences  in  the  degree 
of  warmth  and  of  moisture  by  reflexly  regulating  the  blood 
supply  of  the  mucous  membrane  over  the  turbinate  bones. 

147 


THE  PREVENTION   OF  DISEASE 

In  the  prophylaxis  of  bronchial  affections  much  attention 
must  be  given  to  the  condition  of  the  nose.  Nasal  affections 
must  not  be  regarded  as  purely  local  disturbances,  but  in 
view  of  the  important  part  played  by  the  nose  in  respiration 
should  also  be  regarded  as  important  factors  in  the  pro- 
duction of  serious  and  generally  chronic  affections  of  the 
lower  respiratory  passages.  Diseases  of  the  nose  should 
therefore  be  treated  early.  There  is  a  reflex  action  between 
the  nasal  mucous  membrane  and  the  mucous  membrane  of 
the  finer  bronchial  tubes,  and  for  this  reason  too  it  is  an 
important  prophylactic  measure  to  keep  the  nose  in  a 
normal  condition.  B.  Frankel  and  Voltolini  were  the  first 
to  point  out  that  some  cases  of  bronchial  asthma  are 
connected  with  affections  of  the  nasal  mucous  membrane, 
more  particularlj^"  with  polypi  of  the  nose  and  throat ;  for 
when  the  polypi  were  removed,  the  attacks  of  asthma 
ceased,  but  recurred  when  the  polypi  grew  again.  What- 
ever may  be  our  theory  about  bronchial  asthma,  whether 
we  incline  towards  Biermer's  view  and  regard  contraction  of 
the  muscular  elements  of  the  bronchi  as  the  essential  cause, 
or  whether  towards  Weber's,  and  think  the  essential  cause 
is  the  swelling  of  the  bronchial  mucous  membrane  through 
dilatation  of  the  vessels  and  subsequent  exudation,  never- 
theless it  is  probable  that  central  nervous  influences  are  the 
main  cause,  and  that  the  nasal  affection  can  act  as  the 
exciting  cause  of  the  central  irritation.  So  that  removal  of 
polypi  and  other  affections  of  the  nose  may  be  regarded  as  a 
prophylactic  against  asthma. 

The  maintenance  of  the  natural  elasticity  of  the  lungs  or 
the  prevention  of  emphj^-sema  is  another  important  object 
for  prophylaxis.  Pulmonary  emphysema  is  one  of  the 
most  frequent  pathological  conditions.  Not  only  is  there  the 
primary  essential  emphysema,  but  secondary  emphysema 
sooner  or  later  is  liable  to  develop  after  all  diseases  of  the 
lungs.  In  certain  chronic  pulmonary  affections  and  in 
whooping  cough  in  children  we  should  always  remember 
to  take  measures  to  prevent  emphysema  ;  such  precautions 
are  specially  needed  in  illnesses  accompanied  by  violent  and 
long  continued  attacks  of  coughing,  such  as  occur  in  many 

148 


THE  PEEVENTION  OF  DISEASES  OF  THE  LUNGS 

forms  of  chronic  bronchitis  and  pleural  affections.  Traube 
teaches  that  the  chronic  dry  bronchitis  of  the  finer 
bronchial  tubes  readily  leads  to  emphysema,  less  so  the 
chronic  bronchitis  accompanied  by  copious  expectoration 
and  large  sized  rales.  By  the  forced  efforts  of  expiration 
the  pressure  in  the  thorax  is  so  greatly  increased  that  the 
counter  pressure  exerted  by  the  auxiliary  expiratory 
muscles  of  the  thorax  is  not  sufficient  to  compensate  for  the 
increase  ;  the  alveoli  then  yield  to  the  pressure  and  become 
distended.  Frequent  repetition  of  this  distension  in  course  of 
time  leads  to  the  disappearance  of  the  alveolar  interstices, 
characteristic  of  emphysema.  For  these  reasons,  as  well  as 
for  others,  measures  should  be  taken  to  prevent  those 
violent  paroxysms  of  coughing,  which  are  particularly 
common  in  so-called  "dry  coughs" — either  by  sedatives, 
by  the  avoidance  of  all  causes  that  are  known  to  set  up 
coughing,  by  residence  in  a  suitable  climate,  possibly  in  a 
southern  climate,  or  by  other  means  which  the  physician 
may  find  necessary  for  any  special  case. 

Some  callings  predispose  to  emphysema  of  the  lungs, 
namely  those  which  require  prolonged  and  excessive  respira- 
tory ejfforts,  such  as  the  playing  of  wind  instruments  or 
blowpipe  work ;  packers  and  porters  often  get  emphysema, 
as  the  continuous  strain  due  to  the  heavy  work  is  in 
addition  to  the  compression  of  the  chest,  and  the  expiration 
of  the  air  in  the  lung,  which  is  at  a  greater  pressure  than 
normal,  is  prevented.  Occasionally  emphysema  comes  on 
somewhat  suddenly  in  healthy  people  after  some  un- 
accustomed great  overstrain,  especially  when  in  addition 
there  is  a  predisposition  to  emphysema  brought  on  by  any 
of  the  callings  mentioned  above  ;  it  may  set  in  after  lifting 
a  heavy  weight,  after  excessive  exercise,  such  as  cycling, 
rowing  against  the  wind,  or  wrestling.  Prophylaxis 
naturally  requires  that  all  unaccustomed  overstrain  should 
be  avoided  which  would  make  excessive  demands  upon  the 
activity  of  the  lungs.  Yet  as  in  the  case  of  other  organs,  so 
too  with  the  lungs,  exercise  is  a  valuable  means  of  keeping 
them  sound,  and  when  an  increased  demand  is  made  upon  an 
organ,  the  organ  which  has  not  been  exercised  gives  way, 

149 


THE  PREVENTION  OF  DISEASE 

while  one  which  has  been  exercised  responds  to  the  extra 
demand  and  remains  healthy.  An  hygienic  mode  of  life  by 
exercising  the  lungs  will  preserve  their  elasticity,  and 
walking  is  good  and  deep  breathing  out  in  the  fresh  air,  or 
for  the  young  gymnastics,  out-of-door  games,  running  and 
sports  in  moderation.  Barth  has  lately  in  a  very  interesting 
work  recommended  singing  as  a  preventive  against  diseases 
of  the  lungs,  it  deepens  the  inspirations  and  increases  the 
exchange  of  gases,  and  it  is  at  the  same  time  good 
gymnastic  exercise  for  the  lungs,  which  are  thereby 
accustomed  to  adapt  themselves  to  considerable  variations 
in  breathing. 

To  a  certain  extent  the  diseased  lung  also  is  able  to  adapt 
itself  to  the  demands  made  on  it  by  developing  increased 
respiratory  activity  in  those  parts  of  the  lung  which  are 
still  unaffected.  This  compensatory  hypertrophy  of  the 
healthy  parts  occurs  when  only  small  parts  of  the  lung 
become  successively  affected,  and  there  is  time  afforded  for 
the  healthy  parts  to  adapt  themselves  to  the  demands  made 
upon  them.  There  are  cases  in  which  the  whole  of  one 
lung  has  thus  become  useless,  while  the  other  lung  has 
remained  healthy  and  sufficed  for  the  needs  of  the  body.  In 
cases  of  chronic  bronchitis,  fibrosis,  collapse  of  the  lung,  and 
pleural  adhesions,  the  healthy  lung  tissLie  that  remains  is 
often  sufficient  only  however  when  the  whole  body  is  at 
rest  or  at  the  most  only  slightly  exerted.  The  usual 
result  of  these  affections  is  the  development  of  so-called 
vicarious  emphysema :  the  air  is  unequally  distributed 
through  the  lungs,  and  the  normal  pulmonary  tissue  is 
exposed  to  greater  pressure  and  gradually  becomes  dis- 
tended. This  vicarious  emphysema  develops  the  earlier  the 
greater  the  intra-thoracic  pressure :  that  is,  the  more  the 
diseased  condition  is  disregarded  and  the  greater  the 
demands  made  upon  the  still  healthy  parts  of  the  lungs. 
In  these  chronic  conditions  where  large  parts  of  the  lung 
tissue  are  unable  to  act,  the  amount  of  work  to  be  done 
must  be  very  carefully  regulated  and  over-exertion  avoided, 
so  that  the  increased  functional  activity  of  the  normal  parts 
of  the  lung,  even  when  the  body  is  at  rest,  may  not  be  still 

150 


THE  PREVENTION  OF  DISEASES  OF  THE  LUNGS 

furtlier  increased  and  thus  the  development  of  emphysema 
assisted.  When  the  inflammatory  processes  have  subsided 
or  have  considerably  improved,  methodical  respiratory 
exercises  are  most  valuable  as  a  prophylactic,  gradually  to 
increase  the  functional  activity  of  the  lungs.  For  this 
purpose  graduated  walking  exercise  is  of  value,  and  also 
going  up  and  down  stairs,  a  few  stairs  being  added  from 
time  to  time,  and  other  similar  graduated  exercises. 

Prophylaxis  of  the  various  forms  of  so-called  catarrhal 
pneumonia  is  in  the  wider  sense  similar  to  the  prophylaxis 
of  bronchitis,  in  so  far  as  catarrhal  pneumonia  generally 
follows  bronchitis,  and  rarely  occurs  independently.  It 
follows  therefore  that  when  there  is  bronchitis,  measures 
should  be  taken  to  prevent  catarrhal  pneumonia.  This 
opens  a  wide  field  for  prophylaxis,  especially  in  the  case 
of  children  and  old  people  in  whom  this  form  of  pneumonia 
frequently  occurs.  The  way  in  which  bronchitis  in  children 
must  be  treated  to  prevent  collapse  of  lung  and  the 
development  of  pneumonia  in  these  collapsed  parts  is  dealt 
with  in  the  special  section  on  the  diseases  of  children.  In 
old  people  who  for  any  reason  have  become  bedridden, 
hypostatic  congestion  is  apt  to  cause  the  development  of 
bronchitis  and  broncho-pneumonia,  and  even  lobar  or  so-called 
hypostatic  pneumonia.  Similar  conditions  arise  in  patients 
of  any  age  when  serious  illness  has  confined  them  to  bed  for 
a  long  time  and  when  wasting  and  cardiac  weakness  are 
present,  so  that  the  blood,  obeying  the  law  of  gravitation, 
sinks  to  the  lower  parts  of  the  lungs.  It  is  most  often  met  with 
in  typhoid  fever  after  the  third  week.  The  prevention  of 
hypostatic  congestion  in  such  cases  requires  careful  nursing ; 
the  patient  should  not  lie  always  on  the  back,  other  positions 
should  be  adopted  in  turn,  and  when  possible  the  prone 
position  is  much  to  be  recommended.  Old  people  should  be 
propped  up  as  often  as  possible  and  should  be  confined  to  bed 
only  so  long  as  is  absolutely  necessary.  Old  people  should 
not  for  slight  reasons  be  kept  in  bed,  for  experience  shows 
that  it  is  very  difficult  for  them  again  to  leave  it.  The 
patient  should  several  times  a  day  practise  taking  deep 
inspirations,  and  whenever  possible  should  sit  upright  for 

151 


THE  PREVENTION  OF   DISEASE 

this  exercise.  If  respiration  is  especially  shallow  and  rapid,  it 
must  be  deepened  and  made  slower  reilexly  through,  stimuli 
applied  to  the  skin,  such  as  cold  sponging,  perhaps  lukewarm 
baths  followed  by  douching  with  cool  water.  It  is  also 
useful  to  rub  the  patient  with  spirit  liniments:  a  five  per  cent, 
solution  of  menthol  is  the  best. 

Reference  must  here  be  made  to  serious  pulmonary  affec- 
tions, such  as  bronchitis,  bronchitis  foetida,  broncho-pneu- 
monia and  gangrene,  caused  by  food  particles  getting  down 
the  respiratory  passages,  and  to  the  necessity  of  preventing 
this  in  patients  who  are  very  ill  by  careful  instructions  to 
the  nurse.  In  feeding  such  patients  the  head  must  always 
be  supported  in  the  nurse's  left  hand,  while  with  her  right 
hand  she  gives  food  with  a  teaspoon.  It  is  best  to  raise  the 
patient,  because  in  the  horizontal  posture  food  is  much  more 
easily  drawn  into  the  respiratory  passages  in  inspiration. 
The  patient  should  at  the  same  time  be  asked  to  swallow ; 
the  spoon,  a  teaspoon  being  best,  should  be  carried  as  far 
back  as  possible  into  the  mouth  and  exactly  in  the  middle 
line.  The  sides  of  the  food  passage  are  very  much  more 
sensitive  to  stimuli  than  the  median  parts,  and  if  the  food 
does  not  pass  along  the  median  line  but  touches  the  sensitive 
lateral  walls,  reflex  movements  are  set  up  which  carry  the 
food  into  the  respiratory  tract  with  inspiration.  (Mendelsohn 
and  Gutzmann.)  The  more  the  body  deviates  from  the 
upright  j)Osture  towards  the  horizontal,  the  more  easily, 
especially  in  the  case  of  fluids,  will  food  leave  the  middle 
line  of  the  body  and  flow  towards  the  sides.  To  give  food 
while  the  patient  is  in  the  lateral  position  is  therefore 
obviously  wrong. 


152 


The  Prevention  of  Diseases  of  the  Heart 

BY 

PROF.   MARTIN   MENDELSOHN 

OF  BEELIN 


153 


The  Prevention  of  Diseases  of  the  Heart 

HEAET  LESIONS  AND  HEART  WEAKNESS 

A  "cardiac  lesion"  becomes  a  disease  directly  the  heart 
is  no  longer  able  to  fulfil  completely  at  every  moment  of 
life  the  demands  made  upon  it  which  are  essential  for  the 
maintenance  of  the  functional  activity  of  the  organism. 
No  other  organ  of  the  body  can  be  considered  to  be  similarly 
circumstanced — for  other  organs  when  diseased  or  threatened 
with  disease  may  be  rested  and  for  a  time  saved  from  all 
functional  activity ;  but  this  is  not  possible  with  the  heart, 
which  has  to  act  uninterruptedly  and  continuously  from  a 
time  long  before  the  first  breath  is  drawn  until  the  last 
moment  of  life.  Any  cessation  of  the  heart's  action  would 
mean  cessation  for  ever.  The  heart  then  must  act  cease- 
lessly during  the  whole  of  life ;  it  must  also  constantly  keep 
up  a  circulation  which  shall  be  adequate  for  all  physiological 
processes.  This  is  the  essential  criterion  of  a  clinically  sound 
heart  and  is  indeed  the  only  criterion.  "  Heart  disease  " 
begins — no  matter  whether  the  heart  has  already  undergone 
anatomical  changes  or  not — only  when  the  functional 
activity  of  the  heart  becomes  inadequate  ;  and  the  sole 
object  of  prophylaxis  is  to  prevent  such  a  condition  of 
functional  inadequacy  from  setting  in  prematurely. 

The  prophylaxis  of  heart  disease  has  two  special  features. 
First,  in  those  cases  where  there  is  already  heart  disease 
in  the  purely  anatomical  sense,  but  in  which  the  functional 
activity  of  the  heart  has  not  yet  fallen  below  the  normal, 
the  aim  must  be  to  maintain  this  functional  activity  not- 
withstanding the  anatomical  change:  this  is  prophylaxis 
not  therapeutics.      This  cardiac  lesion  is  not  a  disease  until 

155 


THE  PEEVENTION  OF  DISEASE 

the  functional  activity  begins  to  be  inadequate ;  and  to  pre- 
vent the  development  of  disease  in  spite  of  the  anatomical 
changes  which  are  present  is  in  these  cases  one  of  the  most 
important  objects  of  medicine,  without  which  there  would 
only  be  a  hopeless  struggle  against  irreparable  anatomical 
changes  in  the  muscle  substance  or  the  valves  of  the  heart. 
Prophylaxis  during  the  development  and  course  of  a 
disease  is  probably  of  wider  application  in  heart  disease 
than  in  any  other  branch  of  internal  medicine.  And  the 
second  special  feature  about  heart  disease  is  that  the 
measures  which  are  useful  in  preventing  the  development 
of  functional  disturbances  are  essentially  much  the  same 
for  whatever  form  of  heart  disease  they  may  be  required  ; 
because,  as  already  indicated  above,  the  chief  and  most 
important  object  of  prophylaxis  is  not  so  much  the  possible 
prevention  of  anatomical  changes,  as  the  maintenance  of 
normal  functional  activity  in  a  heart  which  has  already 
undergone  such  changes.  For  this  purpose  the  appropriate 
prophylactic  measures  are  the  same  whatever  be  the 
anatomical  lesion  of  the  heart  which  has  caused  the 
functional  inadequacy. 

The  prophylaxis  of  heart  disease  rests  then  chiefly  upon 
regulating  so  far  as  j)Ossible  the  relation  between  the 
functional  demands  made  upon  the  heart  and  the  functional 
capacity  of  the  organ.  The  aim  of  all  internal  therapeutics 
indeed  is  an  attempt  to  equalize  the  demands  made  upon  an 
organ  and  the  functional  activity  of  that  organ  at  the  same 
time  that  the  possible  duration  of  life  is  not  shortened :  that 
is  to  make  the  relation  which  exists  between  these  two 
magnitudes  a  fraction  in  which  the  numerator  is  equal  to 
the  denominator  ;  and  therapeutics  fulfils  its  object  just  as 
completely  when,  without  ".ny  ill  effect  upon  the  organ  and 
the  whole  body,  it  has  tei  wrarily  or  permanently  reduced 
the  demands  upon  the  or/  to  its  functional  capacity,  as 
when  on  the  other  hand  /  succeeded  in  increasing  the 

functional    activity  thq/  le  demands  made  upon   the 

organ  are  as  great  as  ¥  "When  a  heart  whose  func- 

tional activity  is  reducf  nanently  spared  from  some 

of  its  work  so  that  it  /  liently  to  meet  the  remain- 


THE  PREVENTION  OF  DISEASES   OE   THE  HEAET 

ing  demands  made  upon,  it,  therapeutics  has  completely 
fulfilled  its  object,  and  considered  from  the  standpoint  of 
prophylaxis  has  in  this  way  prevented  an  anatomical  affec- 
tion from  becoming  a  functional  one,  and  a  morphological 
lesion  from  becoming  a  physiological  disease. 

The  quantitative  functional  activity  of  the  heart  is  made 
up  of  two  components :  firstly,  the  minimum  functional 
activity  required  for  the  maintenance  of  an  uninterrupted 
circulation  in  the  body,  when  that  circulation  is  not  made 
more  difficult  or  complicated  by  external  or  internal  influences 
of  any  kind  whatsoever ;  and  secondly,  a  varying  quantity 
of  functional  activity  required  in  addition  to  the  former  to 
meet  the  demands  of  daily  life.  These  demands  result  from 
bodily  and  mental  activity,  or  are  the  effect  of  external 
stimuli  or  of  internal  stimuli  due  to  bodily  functions,  and  to 
the  overaction  of  organs  which  thus  influence  the  distribu- 
tion of  blood,  as  well  as  of  all  the  accidental  occasional 
demands  made  upon  the  heart.  The  former  or  minimum 
of  cardiac  activity  is  approximately  that  of  the  heart  during 
sleep ;  and  this  amount  naturally  cannot  be  reduced  in  any 
way.  But  the  second  component  includes  a  great  amount 
of  work  which  may  be  reduced  ;  and  though  naturally,  even 
when  patients'  surroundings  are  most  favourable,  it  is  not 
possible  to  remove  entirely  all  such  extra  demands  upon  the 
heart,  yet  a  very  large  part  of  such  demands  may  be 
avoided ;  and  when  this  is  carried  out  carefully  and  con- 
tinuously and  above  all  is  done  early  and  adequately,  heart 
disease  may  be  entirely  prevented :  that  is  disturbances 
of  function  may  be  prevented.  This  is  the  task  of 
prophylaxis ;  and  when  we  succeed  in  keeping  a  patient 
who  is  suffering  from  mitral  incompetence  free  from  dis- 
turbances of  function  till  his  eightieth  year  of  life,  the 
defect  of  the  valves  may  possibly  have  some  interest  for 
pathologists,  but  the  physician  considers  throughout  the 
patient's  life  only  the  diminished  functional  activity  of  the 
heart ;  and  it  was  his  duty  to  maintain  the  organism  in  its 
normal  functional  condition  in  spite  of  the  valvular 
deficiency.  Moreover  the  prophylactic  measures  required 
are  the  same  in  any  given  case,  whether   the  diminished 

157 


THE  PREVENTION  OF  DISEASE 

functional  activity  of  the  heart  is  the  result  of  any 
valvular  lesion  or  of  some  other  diseased  condition  which 
reduces  the  power  of  the  heart  muscle. 

For  every  heart — for  the  healthy  heart,  and  still  more  for 
the  heart  predisposed  by  some  heart  lesion  to  the  risk  of 
becoming  incompetent — there  is  a  maximum  of  total  func- 
tional capacity,  up  to  which  maximum  work  may  be  done 
without  injury  to  the  heart.  Of  this  total  quantity  a  certain 
greater  or  less  amount  of  work  is  essential  for  the  "vegeta- 
tive "  or  "  internal "  work  of  the  body.  The  less  capable 
and  efficient  the  heart,  the  greater  is  the  proportion  of  the 
total  work  which  is  required  for  these  internal  functions, 
and  the  smaller  will  be  the  proportion  which  remains  for  the 
various  other  demands  which  may  be  made  upon  the  heart. 
The  relation  may  be  expressed  in  terms  of  political  economy 
as  follows  :  when  the  general  conditions  of  life  have  risen, 
when  prices  have  risen  and  everything  in  the  market 
becomes  dearer,  an  individual  who  has  the  same  fixed  income 
every  year  will  be  obliged  to  spend  a  considerably  larger 
amount  of  his  yearly  income  upon  the  necessaries  of  life, 
house,  dress  and  food,  and  there  will  remain  a  smaller  pro- 
portion of  income  for  luxuries.  So  long  as  a  head  of  a 
family  restricts  his  expenditure  upon  luxuries  to  this  surplus 
of  his  income,  the  two  sides  of  his  account,  the  debtor  and 
the  creditor,  will  balance.  So  too  with  the  heart — if  its 
total  capacity  for  work  has  been  lowered,  a  greater  relative 
part  of  its  functional  capacity  is  required  for  its  indispens- 
able work,  and  prophylaxis  is  concerned  with  seeing  that 
the  surplus  alone  is  expended  upon  other  forms  of  activity, 
in  order  that  the  balance  may  be  maintained. 

For  the  medical  treatment  therefore  of  any  case  it  is  essen- 
tial that  a  diagnosis  of  the  functional  capacity  of  that  indi- 
vidual heart  should  first  be  made.  The  question  is  not  what 
special  morbid  condition  has  affected  this  heart  which  is  to 
be  prevented  from  becoming  incompetent,  but  rather  what 
amount  of  loss  of  functional  capacity  has  it  undergone.  A 
great  and  necessary  step  forward  will  have  been  taken  when 
the  diagnosis  of  diminished  cardiac  capacity  has  been  made, 
and  adequate  prophylactic  measures  have  been  adopted,  before 

158 


THE  PREVENTION  OP  DISEASES  OP  THE  HEART 

those  extensive  and  irreparable  changes  in  the  heart  have 
developed  which  alone  make  a  physical  diagnosis  possible. 

This  is  not  the  place  to  discuss  the  details  of  the  func- 
tional diagnosis  of  heart  disease ;  for  this  reference  should 
be  made  to  textbooks  on  the  diagnosis  and  pathology  of 
cardiac  disease,  especially  the  excellent  one  by  0.  Rosenbach. 
A  truly  scientific  prophylaxis  of  heart  disease  can  only  be 
carried  out  by  the  physician  who  makes  a  functional 
diagnosis,  not  an  anatomical  one.  It  is  not  enough  merely 
to  auscultate  and  percuss,  and  when  nothing  abnormal  has 
been  detected  by  this  procedure  to  conclude  that  special 
prophylactic  measures  are  unnecessary.  Even  when  there  is 
no  such  organic  abnormality  present  in  the  heart,  its  con- 
dition and  functional  capacity  should  be  determined  in 
every  possible  position  of  the  body — when  sitting,  when 
standing,  when  lying  down,  at  rest  and  after  different 
degrees  of  bodily  exertion,  when  the  breath  is  held  and 
during  forcible  respiration,  when  the  abdominal  pressure 
is  increased,  after  a  full  meal,  and  after  much  liquid  has 
been  taken  up  by  the  circulatory  system  through  drinking 
a  large  quantity  of  fluid,  as  well  as  when  other  influences 
have  been  at  work.  In  this  way  by  noting  the  results  of 
such  influences  it  is  possible  to  determine  which  external 
influences  suffice  to  call  forth  pallor,  cyanosis,  coldness 
of  the  extremities,  or  stupor,  giddiness,  pains  over  the 
heart,  and  other  signs  of  cardiac  weakness ;  and  thence 
it  is  possible  to  draw  conclusions  as  to  the  functional 
capacity  of  the  heart.  The  degree  of  limitation  of  func- 
tional capacity  of  the  heart  gives  us  the  clue  to  the  prophy- 
lactic measures  required  for  any  given  case. 


DISEASES  WHICH  PREDISPOSE  TO  CARDIAC  WEAKNESS 

The  most  important  aim  of  prophylaxis  in  heart  disease 
is  to  prevent  cardiac  weakness,  whatever  be  the  nature  of 
the  cardiac  affection  out  of  which  such  cardiac  weakness 
may  arise ;  and  further  whenever  it  is  possible  another 
object  of  prophylaxis  will  be  to  prevent  the  development  of 
conditions  which  will  in  course  of  time  lead  to  cardiac  weak- 

159 


THE  PEEVENTION  OE  DISEASE 

ness.  This  is  extremely  difficult  and  seldom  practicable, 
because  almost  all  lesions  are  secondary  lesions  arising  out 
of  primarj'-  affections,  some  of  wbich  may  date  back  to 
foetal  life  ;  in  these  cases  prophylactic  treatment  to  prevent 
the  cardiac  lesion  is  impossible,  or  is  possible  only  in  so  far 
as  it  is  coincident  with  the  treatment  of  the  primary  affec- 
tion. In  describing  the  prophylaxis  of  heart  disease  it  is 
not  necessary  here  to  describe  in  detail  the  prophylaxis  of 
the  numerous  affections  during  the  course  of  which  myocar- 
ditis, or  more  correctly  myopathic  cardiac  weakness,  may 
develop ;  it  will  suffice  briefly  to  allade  to  these ;  their 
prophylaxis  is  described  elsewhere  and  also  their  treatment. 
The  more  thoroughly  these  affections  are  treated  the  greater 
is  the  possibility  that  the  subsequent  development  of  cardiac 
affections  will  be  prevented. 

The  chief  of  the  affections  which  lead  to  heart  disease  is 
acute  articular  rheumatism.  It  is  obvious  that  the  preven- 
tion of  subsequent  heart  disease  is  best  accomplished  by 
preventing  as  far  as  possible  attacks  of  acute  rheumatism, 
particularly  in  patients  who  have  already  had  an  attack  of 
this  very  dangerous  malady.  The  measures  intended  to 
prevent  articular  rheumatism  itself  are  at  the  same  time 
prophylactic  measures  against  the  endocarditis,  and  need 
not  be  described  here  at  length — a  suitable  method  of  life, 
precautions  after  overheating  the  body,  methods  to  harden 
the  body,  careful  treatment  by  baths  and  friction,  adequate 
clothing  appropriate  to  the  season  of  the  year,  and  many 
other  similar  precautions.  And  when  the  patient  is  attacked 
by  articular  rheumatism  the  most  adequate  treatment  of 
the  rheumatism  will  again  be  the  best  preventive  of  a  heart 
lesion.  There  is  not  however  always  an  exact  relation 
between  the  two.  Although  endocarditis  in  acute  rheuma- 
tism is  doubtless  one  of  the  local  manifestations  of  acute 
rheumatism  which  has  affected  both  the  joints  and  the 
endocardium,  yet  the  severity  of  these  two  local  manifesta- 
tions is  often  very  different.  Often  but  not  always  in  a  case 
of  severe  acute  rheumatism  affecting  many  joints  we  find 
endocarditis  also  well  marked  ;  yet  recently  I  saw  a  case  of 
severe  endocarditis  in  a  mild  attack  of  rheumatism  affecting 

160 


THE  PREVENTION  OF  DISEASES  OE  THE  HEAUT 

only  a  single  joint.  "Whatever  may  be  the  explanation  of 
siicli  exceptional  cases  nevertheless  careful  treatment  of  the 
articular  rheumatism  is  the  most  essential  factor  in  the 
prophylaxis  of  cardiac  disease. 

The  same  remarks  are  applicable  to  all  infective  diseases. 
It  is  well  known  that  endocarditis  and  myocarditis  are  apt 
to  develop  after  measles,  scarlet  fever,  smallpox,  typhoid 
fever  and  pneumonia.  Diphtheria  is  specially  dreaded 
because  of  its  dangerous  effect  upon  the  muscular  substance 
of  the  heart,  which  often  manifests  itself  by  a  sudden  dimi- 
nution of  the  functional  activity  of  the  heart  long  after  the 
diphtheria  has  been  cured  and  while  the  individual  is 
apparently  in  the  best  of  health.  Here  too  the  most 
thorough  treatment  of  the  acute  disease  is  identical  with 
the  prophylaxis  of  the  subsequent  cardiac  affection,  although 
a  mild  and  uneventful  course  of  the  diphtheria  will  not 
necessarily  prevent  the  heart  from  becoming  affected. 

All  febrile  affections,  particularly  when  the  temperature 
has  long  remained  high,  tend  to  cause  cardiac  degeneration 
and  myocarditis,  which  will  be  the  more  severe  and  irre- 
parable the  longer  the  hyperpyrexia  has  lasted.  If,  as 
seems  to  be  the  case,  the  changes  in  the  myocardium  are 
brought  about  not  so  much  by  the  original  cause  or  by  the 
toxines  and  ptomaines  but  by  the  long  continuance  of  the 
high  temperature,  then  antipyretic  treatment  of  the  original 
affection  will  at  the  same  time  be  an  effectual  prophylaxis 
of  the  consecutive  cardiac  weakness. 

Further,  in  all  diseases  which  affect  the  nutrition  of  the 
heart  prevention  and  adequate  treatment  of  the  disease  is 
at  the  same  time  prophylactic  treatment  for  the  heart.  All 
diseases  of  the  blood,  especially  chlorosis,  the  different  forms 
of  anaemia  and  leukaemia,  reduce  the  nutrition  of  the  car- 
diac muscle,  but  if  the  disease  has  not  lasted  too  long  the 
nutrition  of  the  heart  muscle  can  be  restored,  even  though, 
as  often  is  the  case,  the  weakened  myocardium  has  under- 
gone a  slight  degree  of  dilatation.  Here  again  treatment 
of  the  constitutional  disease  is  identical  with  prophylaxis  of 
the  cardiac  affection.  So  too  with  arterio-sclerosis :  it  is 
well  known  that  sclerosis  of  the  coronary  arteries  prevents 

161  M 


THE  PEEVENTION   0¥  DISEASE 

the  efficient  nutrition  of  the  heart,  damages  the  heart 
muscle  and  gives  rise  to  serious  symptoms. 

This  is  also  true  about  poisons  :  prevention  of  the  original 
cause  is  prophylaxis  for  the  heart.  Phosphorus  is  the  most 
important  of  these  poisons.  In  close  relation  with  it  are 
acute  yellow  atrophy  of  the  liver  and  similar  degenerative 
processes  which  give  rise  to  cardiac  degeneration. 

Special  mention  must  be  made  of  obesity.  The  fat  accu- 
mulates in  large  masses  beneath  the  epicardium  and 
mechanically  hinders  the  movements  of  the  heart ;  or 
layers  of  fat  may  extend  between  the  bundles  of  muscle 
fibres,  or  the  muscle  substance  of  the  heart  may  itself  later 
undergo  fatty  degeneration  and  become  less  and  less  capable 
of  contracting.  The  prophylactic  measures  are  those  for 
obesity  in  general,  for  they  will  tend  to  prevent  this  form 
of  weakness  of  the  heart  at  the  same  time  as  they  prevent 
the  general  obesity. 

INDIVIDUAL  CAEDIAC  TUNCTIONAL  CAPACITY 

Although  in  many  cases  the  preventive  and  curative 
treatment  of  various  diseased  conditions  will  serve  at  the 
same  time  to  prevent  cardiac  lesions,  yet  there  are  cases 
which  we  must  now  consider  by  themselves  in  which  the 
physician  is  called  upon  to  treat  existing  cardiac  lesions 
which  are  anatomically  irreparable,  and  to  devise  suitable 
prophylactic  measures.  Many  individuals  are  exposed  to 
the  danger  of  cardiac  insufficiency  though  they  have  never 
suffered  from  articular  rheumatism  nor  from  any  of  the 
primary  diseases  enumerated  above  which  are  apt  to  affect 
the  heart.  Those  with  "sound  hearts"  as  well  as  those  with 
"  diseased  hearts  "  should  be  considered  by  the  physician  in 
respect  to  prophylaxis  because,  as  we  stated  at  the  begin- 
ning, one  of  the  most  valuable  and  most  satisfactory  tasks  of 
the  physician  is  to  suggest  prophylactic  measures  to  prevent 
cardiac  insufficiency  from  developing.  Just  as  the  optical 
apparatus  of  every  eye  possesses  its  own  power  of  refraction 
and  every  biceps  muscle  has  its  own  power  of  contraction, 
so  too  every  heart  has  its  own  total  functional  capacity, 
the  differences  in  capacity  being  the  result  either  of  indi- 

162 


THE  PREVENTION  OF  DISEASES  OF  THE  HEART 

vidual  idiosyncrasies  of  the  heart  itself  or  of  the  mode  of 
life,  or  more  especially  of  the  after  effects  of  other  diseases 
which  have  affected  the  muscle  or  valves  of  the  heart.  To 
estimate  this  individual  functional  capacity  and  then  to 
adapt  the  life  to  the  capacity  of  the  heart  is  the  aim  of 
prophylaxis  in  heart  disease. 

In  describing  prophylaxis  it  is  necessary  to  consider  one 
by  one  the  various  symptoms  which  may  arise  from  heart 
disease.  Then  we  shall  consider  the  main  causes  in  every- 
day life  which  tend  to  injure  the  heart,  and  especially  a 
heart  already  threatened  with  insufficiency,  and  then  shall 
take  into  consideration  how  in  daily  life  these  injurious 
effects  may  be  prevented. 

REST  AND  ACTIVITY 

The  most  important  of  the  measures  for  preventing  the 
heart  from  becoming  insufficient  is  the  regulation  of  the 
amount  of  physical  work  which  the  patient  may  do.  Dur- 
ing the  last  ten  years,  mainly  through  Oertel's  vigorous 
and  energetic  initiative,  the  statement  has  been  made  that 
every  heart  which  has  been  weakened  by  disease  of  its 
valves  or  of  its  muscle  substance  or  from  any  other  cause 
may  be  strengthened  by  methodical  exercise,  that  by  steady 
and  gradual  increase  of  the  demands  made  upon  the  heart 
a  large  amount  of  compensatory  hypertrophy  may  somehow 
be  established,  and  the  heart  be  thus  rendered  permanently 
capable  of  satisfactorily  doing  its  work.  This  opinion, 
especially  when  stated  as  a  general  fact,  is  surely  incorrect. 
Nature  in  the  wise  and  inscrutable  efforts  she  makes  for  the 
preservation  of  the  individual  certainly  produces  a  compen- 
satory hypertrophy  of  some  part  of  the  heart  when  that 
part  is  unable  efificiently  to  fulfil  its  work.  That  is  doubt- 
lessly correct.  But  the  amount  of  the  hypertrophy  required 
and  the  degree  of  hypertrophy  beyond  which  it  may  not  be 
arbitrarily  increased  can  only  be  determined  by  the  organism, 
never  by  the  physician.  All  cardiac  hypertrophy  must 
rather  be  looked  upon  as  a  makeshift,  a  using  up  of  the 
capital  instead  of  the  interest  on  the  capital,  and  clinical 
experience  is  continually  showing  us  that  even  when  such 

163 


THE  PREVENTION   OF  DISEASE 

liypertrophy  of  the  heart  has  in  any  individual  case  restored 
the  functional  activity  of  the  heart  to  its  normal  amount, 
the  hypertrophied  muscle  produced  by  the  increase  in  the 
work  soon  gives  way.  The  object  of  well  devised  prophy- 
lactic measures  is  not  the  attainment  of  a  merely  momentary 
increase  of  functional  activity.  "When  the  heart  muscle  is 
degenerating,  either  indirectly  through  excessive  demands 
upon  its  activity  as  with  valvular  lesions,  or  directly 
through  changes  affecting  the  muscle  as  in  myocarditis,  it 
is  never  possible,  least  of  all  by  renewed  and  oft  repeated 
over  exertion,  to  increase  its  contractile  power  beyond  the 
limit  which  its  constitution  has  fixed  and  convert  it  into 
energy.  When  it  has  apparently  been  possible  by  such 
exercise  to  produce  hypertrophy  and  increase  the  heart's 
strength,  we  have  merely  built  up  one  part  at  the  expense 
of  another,  and  the  greater  the  hypertrophy  thus  built  up 
the  more  quickly  does  the  degeneration  proceed.  But  this 
is  the  very  thing  we  have  to  prevent.  The  object  of  pro- 
phylaxis should  be  to  maintain  cardiac  compensation  as 
long  as  possible,  and  the  attempt  to  stimulate  the  heart  to 
increased  activity  by  exercise  will,  as  soon  as  the  increased 
demands  made  upon  it  are  excessive,  produce  cardiac  insuffi- 
ciency which  may  be  temporary  or  even  permanent.  I  have 
often  observed  this  in  clinical  practice,  and  quite  agree  with 
Liebermeister  who  says  that  death  has  been  hastened  in 
many  cases  of  heart  disease  during  the  last  few  years.  "  A 
good  horse  dies  in  the  shafts  "  when  the  driver  is  ignorant. 
It  is  true  that  exercise  for  the  cardiac  muscle  is  indicated 
sometimes  :  in  cases  in  which  the  muscle  itself  is  healthy 
and  the  diminished  functional  activity  is  caused  mechanic- 
ally by  deposits  of  fat  outside  the  muscle  substance.  The 
conditions  are  then  similar  to  those  met  with  in  the  arm 
muscles  of  an  athlete,  which  are  normal  and  healthy  in 
themselves,  but  which  have  not  yet  reached  the  highest 
possible  degree  of  development,  and  therefore  may  be 
strengthened  by  systematic  exercise.  Those  persons  in 
whom  want  of  activity  has  reduced  the  cardiac  power 
may  supply  this  want  by  systematic  exercise  which  makes 
demands  upon  the  heart,  increasingly  greater  and  greater, 

164 


THE  PREVENTION  OF  DISEASES  OF  THE  HEART 

and  thus  increases  its  functional  activity.  Even  here  we 
must  act  slowly  and  with  moderation,  and  the  condition  of 
the  functional  activity  of  the  heart  should  be  carefully  and 
constantly  watched  ;  even  the  very  slightest  degree  of  over- 
strain must  be  avoided,  because  it  is  well  known  that  over- 
strain may  seriously  affect  a  heart  which  was  originally 
perfectly  healthy. 

One  single  acute  over  exertion  may  lead  to  acute  dilata- 
tion. This  depends  partly  upon  the  severity  of  the  sudden 
over  exertion,  but  still  more  upon  the  heart  itself  and  its 
individual  capacity  of  reacting  against  the  injury.  This 
shows  how  important  it  is  that,  as  already  stated,  the 
functional  capacity  of  the  heart  should  be  examined  in  every 
patient.  It  is  most  valuable  in  such  a  case  to  have  made 
the  discovery  that  the  heart  responds  by  signs  of  commen- 
cing insufficiency  to  a  certain  amount  of  extra  demand 
made  upon  it,  and  thus  be  able  to  warn  the  patient  against 
future  exertions  which  are  beyond  the  capacity  of  his 
heart,  and  so  save  him  from  developing  cardiac  insufficiency. 
The  observation  has  often  been  made  that  severe  infective 
disease  leaves  the  heart  so  weak  that  the  mere  effort  of 
raising  himself  up  in  bed  has  caused  the  patient  to  faint : 
here  the  mere  physical  effort  of  raising  himself  has  over- 
strained the  heart.  In  a  considerable  number  of  other  cases 
too,  some  one  excessive  bodily  effort  has  sufficed  to  call  forth 
signs  of  cardiac  incompetence.  Prophylaxis  is  here  of  the 
utmost  importance,  and  when  we  have  determined  with 
tolerable  certainty  the  functional  capacity  of  the  heart, 
whether  this  be  normal  or  subnormal,  and  the  amount  of 
extra  exertion  of  which  it  is  capable  without  injury,  we  are 
able  to  forbid  all  that  would  cause  overstrain. 

An  even  more  important  cause  of  injury  to  the  heart, 
because  less  obvious  and  very  common,  is  over  exertion  at 
sports  and  especially  in  cycling.  Several  years  ago  I 
pointed  out  that  cycling  is  characterized  by  the  peculiarity 
that  the  strain  and  overstrain  caused  by  that  form  of 
physical  exercise  are  not  subjectively  felt  by  the  cyclist  in 
the  same  degree  as  in  other  forms  of  physical  exertion ;  and 
that  fatigue  and  the  need  for  rest  are  not  felt  till  some  time 

165 


THE  PEEVENTION  OF  DISEASE 

after  excessive  demands  have  been  made  upon  tlie  heart, 
and  during  this  time  the  heart  has  been  subjected  to  consid- 
erable overstrain.  A  careful  prophylaxis  is  very  essential 
in  this  connection ;  the  functional  capacity  of  the  heart, 
whatever  be  its  condition,  should  be  carefully  estimated, 
and  the  effect  of  cycling  noted  before  it  is  permitted 
as  an  exercise,  and  even  the  strongest  cyclist's  heart 
should  be  watched  and  the  exercise  regulated  and  adapted 
both  in  kind  and  in  degree  to  its  capacity.  Where  these 
precautions  have  not  been  observed,  serious  injury  and  not 
a  few  cases  of  sudden  death  have  been  known  to  result  from 
cycling.  The  same  is  true  of  running,  and  of  rowing,  of 
mountain  climbing  and  of  all  forms  of  excessive  and  contin- 
uous physical  exertion. 

A  more  difEcult  task  confronts  the  physician  when  the 
over  exertion  is  necessitated  by  the  patients'  occupation, 
and  he  cannot  regulate  this  as  he  can  the  amount  of 
cycling.  The  regulation  of  the  amount  of  physical  exercise 
is  the  more  necessary  as  a  prophylactic  measure,  because  in 
many  occupations  where  men  have  to  work  hard,  several 
injurious  factors  are  apt  to  be  combined,  all  of  which  cause 
injury  to  the  heart ;  for  example,  Jiirgensen  has  pointed 
out  that  the  "  Tubingen  heart,"  a  myopathic  form  of 
cardiac  insufficiency  which  is  so  common  in  the  district  of 
Tubingen  among  the  people  who  are  employed  in  the  vine- 
yards, is  to  be  attributed  to  the  fact  that  the  men 
have  to  carry  heavy  weights  and  at  the  same  time  go  up 
the  steep  mountain  sides.  Similar  conditions  are  met  with 
in  those  who  carry  heavy  weights  and  in  boatmen  and  in 
similar  callings,  particularly  when  these  individuals  are 
accustomed  to  take  much  alcohol.  Restriction  of  alcohol 
is  a  valuable  prophylactic,  because  alcohol  has  been  proved 
to  injure  the  heart. 

Rest  not  exercise  is  therefore  the  main  principle  in  the 
prophylaxis  of  heart  disease  ;  and  our  duty  is  to  reduce  the 
amount  of  physical  exercise  and  not  to  increase  it.  The 
activity  of  the  heart  is  increased  directly  in  proportion  to 
the  physical  exercise.  This  is  effected  through  the  nervous 
system  which  is  constantly  regulating  the  activity  of  the 

166 


THE  PREVENTION  OF  DISEASES  OF  THE  HEART 

heart,  so  that  whenever  metabolism  is  increased — especially 
by  muscular  exercise — the  heart's  action  is  at  once  increased 
in  proportion  ;  and  a  heart  which  expends  all  or  most  of 
its  functional  activity  in  the  mere  "  vegetative  "  carrying 
on  of  the  circulation,  must  be  spared  from  further  demands 
upon  it  made  by  avoidable  physical  exercise.  The  exercise 
should  be  restricted  and  reduced  to  a  minimum.  The  in- 
creased demands  made  upon  such  a  heart  by  phj'-sical  exercise 
must  never  exceed  those  which  can  be  responded  to  without 
causing  any  sign  of  commencing  cardiac  insufficiency,  those 
for  which  the  heart  still  possesses  a  sufficient  surplus  of 
functional  activity.  In  other  words,  rest  is  the  first  essen- 
tial in  the  prophylaxis  of  heart  disease. 

THE  FORM  AND  AMOUNT  OF  REST  FOR  THE  HEART 

Thorough  rest  for  the  heart  should  at  once  be  commenced 
and  most  carefully  carried  out  in  cases  where  an  acute  sudden 
reduction  in  the  heart's  functional  capacity  has  occurred  in 
the  course  of  acute  endocarditis  or  of  any  of  the  severe  ill- 
nesses which  are  apt  to  injure  the  heart  muscle.  No  great 
extra  demand  must  be  made  upon  the  heart,  sometimes  indeed 
no  extra  demand  at  all,  until  the  organ  has  gradually  been 
restored  to  its  normal  functional  activity.  The  patient 
should  be  kept  at  absolute  rest  in  bed.  If  there  is  valvular 
disease  the  rest  in  bed  should  continue  till  adequate  compen- 
sation has  developed. 

It  is  obviously  impossible  for  every  individual  whose 
heart  is  not  functionally  quite  healthy  to  remain  in  bed 
all  his  life  or  to  be  wholly  inactive  :  every  one  desires  to  use 
his  life  and  also  to  enjoy  life,  and  a  sensible  man  does  both 
only  up  to  the  degree  which  is  reasonable  for  him.  Our  task 
is  to  determine  the  amount  of  rest  and  of  activity  possible  for 
each  individual  who  needs  to  take  precautions  on  account 
of  his  heart,  and  to  show  how  this  is  possible  in  ordinary 
life.  The  total  activity  of  which  a  heart  is  capable  consists 
of  two  parts.  Firstly,  a  constant  part  which  is  continuously 
and  uninterruptedly  required  for  "  vegetative"  cardiac  work, 
for  the  simple  carrying  on  of  the  circulation  of  the  blood.  And 
secondly,  an  inconstant  part — a  surplus  constantly  varying 

167 


THE  PREVENTION  OF  DISEASE 

in  amount  and  dependent  upon  the  sum  of  all  the  stimuli 
both  external  and  internal  which  act  upon  the  body.  Thus 
there  is  for  every  individual  a  certain  definite  "  physiological 
latitude"  in  the  external  influences  which  may  be  brought 
to  bear  upon  the  body — all  the  bodily  and  mental  stimuli. 
Upon  the  metabolism  which  results  from  these,  and  upon 
the  regulation  of  the  heart  through  special  nerve  centres, 
the  activity  of  the  heart  at  any  time  depends. 

Physical  exercise  is  the  most  important  and  most  frequent 
of  these  stimuli.  This  physiological  latitude  of  the  stimuli 
which  act  upon  the  heart  is  subject  to  great  variations, 
and  the  heart  remains  efficient  within  certain  limits.  The 
lower  limit  is  that  amount  of  work  done  by  the  heart  when 
the  body  is  at  rest  and  inactive,  which  is  necessary  merely 
to  carry  on  the  vegetative  function  of  the  circulation  of  the 
blood  ;  the  upper  limit  is  the  maximum  of  work  which  the 
heart  can  perform,  and  represents  the  largest  possible  sum 
of  stimuli  which  can  excite  the  heart  to  increased  activity 
without  making  it  inefficient.  "When  the  functional  activ- 
ity of  the  heart  is  small  in  itself  or  has  become  small  by 
reason  of  acquired  changes  in  the  heart,  then  a  large  pro- 
portion of  its  total  functional  activity  will  be  expended 
upon  carrying  on  the  circulation  while  the  circulation  is 
uninfluenced  in  any  way,  and  a  very  small  part,  often  a 
mere  trifle  of  the  heart's  functional  activity,  remains  over 
for  possible  use  when  demands  are  made  upon  it. 

This  is  of  the  greatest  significance  in  connexion  with 
prophylaxis.  Such  a  heart  uses  up  a  large  part  of  its 
reserve  strength  in  merely  maintaining  the  circulation  of 
blood,  which  in  a  healthy  heart  would  be  ready  for  use  for 
physical  and  mental  activity  and  all  the  other  influences  of 
life.  The  physiological  latitude  of  such  a  heart  is  a  very 
small  one,  and  the  limit  up  to  which  the  heart's  action  may 
be  increased  by  activity,  especially  by  physical  activity, 
without  overstrain  to  the  heart,  is  a  very  low  one.  The 
object  of  prophylaxis  is  to  restrict  bodily  activity  to  an 
amount  which  will  not  cause  the  heart  to  work  beyond  this 
small  physiological  latitude. 

Reference  has  several  times  been  made  to  the  diagnosis 

168 


THE  PREVENTION  OF  DISEASES  OF  THE  HEART 

of  the  heart's  functional  capacity,  and  when  it  becomes 
necessary  to  adopt  prophylactic  measures  in  any  individual 
case,  the  physician  can  by  repeated  examination  quite  well 
form  an  opinion  about  the  physiological  latitude  beyond 
which  the  cardiac  activity  must  not  be  called  forth  by 
stimuli.  He  can  find  out  what  is  the  maximum  increase 
of  activity  which  the  heart  which  has  been  working 
quietly  while  at  rest  can  be  called  upon  to  perform,  and 
thence  can  fairly  accurately  prescribe  the  amount  of 
physical  exercise  which  any  given  individual  may  take  in 
addition  to  the  other  demands  made  upon  that  heart.  But 
it  is  of  course  very  difficult  and  often  impossible  to  put 
side  by  side  the  many  factors  which  in  the  form  of  stimuli 
combine  to  raise  the  activity  of  the  heart  when  the  indi- 
vidual is  at  work,  and  to  estimate  their  mutual  quantita- 
tive relations  and  thus  be  able,  not  only  to  prescribe  the 
amount  of  bodily  activity  permissible,  but  also  the  amount 
of  the  manifold  other  activities.  We  can  therefore  give 
the  patient  only  general  directions,  can  explain  to  him  so 
far  as  possible  the  nature  of  his  condition  and  further  urge 
upon  him  the  duty  of  recognizing  and  keeping  within  the 
limits  which  he  must  not  overstep.  If  the  physician  has 
thus  properly  instructed  the  patient  and  if  the  patient  will 
carefully  observe  himself  he  will  be  far  better  able  to  guide 
his  way  aright  than  if  he  followed  some  scheme  of  rules 
drawn  up  for  him. 

To  do  this  he  must  be  guided  by  his  subjective  sensations. 
They  constitute  an  extremely  good  sign  of  commencing 
disturbance  of  compensation  and  of  commencing  excess  in 
the  demands  upon  the  heart.  First  there  is  palpitation  of 
the  heart,  felt  whenever  the  patient  has  undergone  bodily 
exercise  which  is  too  severe  or  too  long  continued.  One 
must  not  think  that  hypertrophy  of  the  heart  produces 
palpitation  because  the  hypertrophied  heart  increases  the 
heart's  activity  ;  that  is  not  the  case.  The  subjective  sensa- 
tion of  palpitation  is  never  produced  by  hypertrophy  but 
is  always  a  sign  whenever  it  occurs  that  demands  are  being 
made  upon  the  heart  which  are  beyond  its  capacity. 
Dyspnoea  has  a  similar  significance.     In  the  prophylaxis 

169 


THE   PEEVENTION  OF  DISEASE 

of  heart  disease  patients  should  be  told  to  notice  when 
palpitation  or  shortness  of  breath  is  produced  by  physical 
exertion,  to  discontinue  the  exertion  directly  either  of 
these  symptoms  appears,  to  rest,  and  not  to  resume  the 
physical  exertion  until  these  signs  have  completely  dis- 
appeared. Such  self  observation  is  not  always  easy,  because 
the  patient  has  to  be  on  the  lookout  for  the  onset  of  two 
symptoms  which  are  not  very  noticeable  and  are  often  over- 
looked and  unobserved  by  indolent  individuals  and  by 
people  who  are  not  very  sensitive,  and  particularly  by 
people  belonging  to  the  working  classes  who  are  under  the 
impression  that  pain  or  some  very  obvious  severe  disturb- 
ance is  the  only  sign  of  illness.  Others  too,  even  people 
with  the  highest  and  most  delicate  organization,  often  show 
remarkable  carelessness  as  to  the  importance  of  subjective 
symptoms.  In  such  cases  we  must  with  the  assistance  of 
the  patient's  friends  employ  the  frequency  of  the  pulse  as 
the  test  of  the  amount  of  bodily  exertion  which  is  desir- 
able. A  patient  whose  heart  is  not  sound  must  never 
attempt  bodily  exertion  which  makes  his  pulse  beat  more 
than  one  hundred  times  per  minute.  Directly  the  pulse 
has  reached  this  frequency  the  patient  must  cease  exercise 
and  must  rest  the  heart  completely  imtil  the  pulse  rate  has 
again  fallen  to  the  normal.  Exercise  approximately  up 
to  the  limit  of  the  heart's  functional  activity,  and  cessation 
of  all  exercise  at  the  very  first  and  most  transient  sign  of 
cardiac  tiredness,  and  resumption  of  activity  only  after  the 
heart  has  completely  recovered  itself — such  heart  exercise 
only  may  be  practised  by  a  patient  with  diminished 
functional  activity,  and  such  exercises  only  are  useful. 

It  has  already  been  pointed  out  that  only  a  normal 
muscle  which  has  undergone  no  degeneration  is  capable  of 
being  developed  by  exercise,  and  reference  was  made  to 
the  biceps  muscle  of  athletes  as  a  case  in  point.  Though 
exercise  of  the  healthy  muscle  will  with  certainty  develop 
its  strength,  it  would  be  folly  to  exercise  that  muscle  if 
myositis  were  present.  It  is  exactly  the  same  with  the 
heart,  and  let  us  once  more  clearly  state  that  these  principles 
apply  to  all  forms  of  heart  disease,  whether  the  result  of 

170 


THE  PEEVENTION  OF  DISEASES  OF  THE  HEART 

valvular  lesions  or  of  alteration  of  the  muscle  substance 
itself,  and  that  in  this  respect  we  may  consider  these  diseases 
collectively.  Finally  all  diseases  of  the  heart  of  whatever 
kind  are  diseases  of  the  muscle  substance  ;  even  valvular 
disease,  the  importance  of  which  has  recently  been  experi- 
mentally proved  by  Eomberg,  Krehl,  His,  Eosenbach  and 
others  to  be  due  less  to  the  lesion  of  the  valve  than  to  the 
resulting  insufficiency  of  the  cardiac  muscle. 

On  the  one  hand  to  compel  an  inefficient  muscle  to  work 
beyond  the  limit  of  its  capacity,  and  on  the  other  daily 
and  systematically  to  stimulate  a  muscle  to  work  up  to  the 
limit  of  its  capacity  and  to  maintain  or  even  to  increase  this 
capacity,  are  two  very  different  things.  A  superficial  con- 
sideration might  seem  to  suggest  that  it  is  desirable  to 
keep  the  patient  at  absolute  rest  and  not  permit  any  extra 
demands  whatever  to  be  made  upon  the  heart ;  such  however 
is  not  the  case,  but  an  endeavour  must  rather  be  made  to  keep 
the  heart  up  to  its  greatest  functional  capacity  and  never 
allow  it  to  go  in  the  least  beyond.  The  subjective  sensa- 
tions of  the  patient  are  the  surest  guide  for  keeping  within 
these  limits  when  both  physician  and  patient  are  striving 
to  keep  the  heart  from  becoming  incompetent  by  overstrain. 
It  is  often  possible  in  this  way  to  increase  the  heart's 
activity  very  considerably.  After  the  development  of  an 
acute  heart  lesion  the  total  strength  of  the  heart  may  have 
sunk  so  considerably  and  the  physiological  latitude  be  so 
small  that  the  additional  demands  made  upon  the  heart  even 
by  simply  trying  to  raise  himself  up  in  bed  may  cause  the 
patient  to  faint.  Such  a  patient  must  be  kept  altogether  in 
bed  till  the  heart  has  recovered  its  strength  or  compensation 
has  set  in  ;  but  as  soon  as  the  patient  is  able  to  raise  himself 
in  bed  he  should  daily,  very  slowly  and  carefully  and  under 
constant  supervision,  exercise  the  heart  up  to  the  limit  of 
its  strength  by  bodily  movements. 

Thus  he  will  gradually  succeed  in  doing  more  and  more 
and  may  be  further  helped  afterwards  by  those  "  exercises 
against  resistance  "  which  are  so  much  used  at  the  present 
moment.  If  these  "  resistance  exercises,"  which  should 
always  be  given  by  the  physician  himself  and  never  by 

171 


THE   PREVENTION  OF  DISEASE 

the  aid  of  a  machine,  do  not  exceed  the  strength  of  the 
patient  at  any  time,  they  are  curative,  and  act  in  the  same 
way  as  the  other  methods  sketched  above  for  systematically 
strengthening  the  heart.  When  with  much  patience  and 
care  the  heart  has  in  this  way  been  long  enough  exercised 
— and  "  exercise  "  merely  denotes  working  the  organ  to  the 
capacity  of  its  function  and  not  exceeding  it  at  any  time — 
then  the  patient  will  finally  be  able  to  bear  without  any 
bad  after  effects  occasional  greater  demands  made  upon 
his  heart  temporarily,  such  as  are  unavoidable  in  everyday 
life.  If  however  such  excessive  demands  are  made  too 
frequently,  especially  soon  after  the  heart  injury  was 
sustained,  or  the  demands  are  made  regularly  and  system- 
atically by  the  medical  order  of  a  physician  who  has 
taken  a  wrong  view  of  the  condition  of  the  cardiac  muscle, 
then  cardiac  insufficiency  will  be  developed  even  earlier 
than  it  would  have  been  had  such  exercise  been  omitted. 

MENTAL    BEST 

A  further  important  part  of  prophylaxis  is  mental  rest 
and  the  prevention  of  too  great  an  increase  of  the  heart's 
activity  as  the  result  of  mental  stimuli.  It  is  obvious 
that  this  is  too  complicated  to  permit  us  to  draw  up  a 
simple  scheme  of  rules ;  the  main  outlines  can  alone  be 
sketched  and  will  enable  the  intelligent  physician  to  form 
an  opinion  in  any  given  case  and  draw  up  rules  for  it. 

It  is  well  known  that  mental  stimuli  excite  the  heart's 
action  just  as  do  bodily  stimuli.  Here  also,  though  less 
obviously,  we  see  the  great  regulating  power  possessed  by 
the  organism  which,  acting  through  the  nervous  system, 
adequately  increases  the  heart's  movements  whenever 
there  is  increased  metabolism  at  any  part  of  the  body  with 
the  object  of  replacing  the  used-up  material  as  rapidly  as 
possible.  And  as  it  is  necessary  to  limit  bodily  exercise  to 
the  reduced  capacity  of  the  cardiac  activity  in  any  case, 
so  too  it  becomes  necessary  adequately  to  limit  severe 
mental  exertion.  The  strain  of  mental  exercise  acts  upon 
the  heart  just  as  physical  exercise  does,  and  may  act  upon 
the  heart    to   such    a   degree    that,    combined   with  other 

172 


THE  PREVENTION  OF  DISEASES  OF  THE  HEART 

unavoidable  demands  upon  it,  the  limit  of  tlie  heart's 
capacity  is  overstepped.  Reading  especially  should  be 
regulated  both  in  amount  and  in  kind.  It  is  a  recreation 
and  diversion  in  which  23atients  whose  heart  condition  pre- 
vents much  physical  activity  are  very  apt  to  over-indulge. 
Sudden  emotion,  which  is  another  form  of  mental  excite- 
ment, must  be  j^revented  and  guarded  against  even  more 
carefully  than  regular  and  long  lasting  mental  exertion. 
Patients  suffering  from  heart  disease  should,  so  far  as  it  is 
possible  in  the  imperfect  regulation  of  our  human  life,  be 
shielded  completely  from  everything  that  would  arouse  in 
them  terror,  anger,  excitement,  sorrow  or  worry.  Natur- 
ally this  is  more  easily  said  than  done.  But  much  of  the 
harm  is  caused  by  the  thoughtless  unsympathetic  friends 
around  the  patient,  and  with  great  care  it  is  possible  to  save 
him  from  some  of  this — sometimes  from  much,  sometimes 
from  little.  All  such  mental  excitement  and  depression 
which  act  strongly  on  the  organism  are  as  injurious  to 
the  heart  as  sudden  very  severe  physical  over  exertion, 
and  may  disturb  for  a  long  time  or  even  permanently  a 
compensation  which  was  previously  well  maintained.  They 
do  harm  not  only  by  increasing  the  heart's  activity  but 
also  by  direct  action  upon  the  nervous  apparatus  of  the 
heart,  and  as  a  result  they  prevent  the  proper  nutrition  of 
the  body  and  of  the  heart. 

In  connexion  with  this  regulation  of  mental  excitement 
there  is  an  important  factor  to  be  noted,  both  in  the 
interest  of  the  patient  and  of  the  physician ;  a  factor 
which  under  certain  circumstances  exercises  the  most 
injurious  action  upon  the  body.  This  factor  is  the  opinion 
which  the  patient  has  formed  and  holds  about  his  "  heart 
disease"  and  the  symptoms  which  it  has  produced.  In 
regard  to  this  the  physician  can  be  of  the  greatest  help  to 
the  patient  entrusted  to  his  care.  We  have  already  pointed 
out  how  the  individual  patient  might  judge  of  the  amount 
of  bodily  exercise  of  which  he  is  capable,  by  observing  the 
condition  of  his  heart  during  exertion  and  noticing 
symptoms  of  palpitation,  shortness  of  breath  and  increased 
frequency  of   the  pulse.       But  patients    can    only   do    so 

173 


THE  PREVENTION  OF  DISEASE 

without  injurious  results  when  they  have  been  suffi- 
ciently instructed  and  know  which  symptoms  are  impor- 
tant and  which  symptoms  have  little  or  no  signifi- 
cance. Patients  who  have  heart  disease  or  think  they 
have  it  anxiously  watch  every  symptom  which  seems 
to  be  connected  with  the  heart's  action,  and  are  only  too 
apt  to  regard  the  most  trivial  and  natural  symptoms  as  bad 
and  dangerous.  The  mental  effect  of  this  reacting  upon 
the  heart  is  extremely  bad.  They  must  be  taught  that  the 
symptoms  are  not  all  of  significance.  The  constant  atten- 
tion which  they  bestow  upon  their  heart  reacts  upon  the 
heart  through  the  increased  mental  activity  which  it  calls 
forth,  and  increases  the  heart's  action  and  constitutes  a 
"  vicious  circle."  So  too  when  attention  is  given  to  it 
palpitation  is  much  more  quickly  and  readily  noticed  and 
observed  than  when  such  an  interest  in  the  subject  has 
not  been  artificially  stimulated.  It  is  very  necessary  to 
explain  to  the  patient  that  it  is  perfectly  normal  that  he 
hears  distinctly  the  beating  of  his  heart  when  he  lies  in 
bed  at  night  with  one  ear  to  the  pillow;  and  that  every 
one,  even  one  with  the  soundest  and  most  capable  heart, 
will  plainly  feel  the  heart  beating  whenever  he  assumes 
any  position  in  which  the  heart,  from  the  way  in  which 
it  is  suspended,  comes  to  lie  heavily  against  the  chest. 
The  same  result  may  be  brought  about  in  the  reverse 
way,  when  the  chest  wall  is  pressed  up  against  the  heart 
by  leaning  against  some  firm  object  or  by  pressure  of  the 
clothes  and  many  similar  causes.  And  other  physio- 
logical changes  in  the  heart's  action  must  also  be 
explained  to  the  patient.  These  changes  are  met  with  in 
every  one  ;  they  remain  unobserved  and  unnoticed  by  the 
healthy  individual  but  are  readily  observed  by  a  patient 
who  has  heart  disease,  and  are  apt  also  to  be  more  marked 
because  the  diseased  heart  reacts  quickly  to  slight  stimuli  : 
for  example  the  fact  that  the  pulse  becomes  irregular  when 
the  breath  is  held  for  long  should  be  mentioned  and 
explained  to  these  excessively  anxious  and  sceptical  persons, 
so  that  they  may  know  how  unimportant  this  is.  And  it 
is  only  when   they   are   no  longer  unnecessarily  anxious 

174 


THE  PREVENTION  OF  DISEASES  OF  THE  HEART 

about  cardiac  symptoms  that  mental  prophylaxis  may  be 
considered  adequate. 

In  order  that  such  mental  prophylaxis  may  be  successful 
the  patient  must  have  absolute  confidence  in  the  physician. 
Confidence  in  the  physician  is  a  general  and  necessary  con- 
dition for  the  successful  treatment  of  all  diseases,  but  is 
probably  of  greater  value  in  heart  disease  than  in  any  other. 
The  various  signs  and  symptoms  of  their  cardiac  trouble 
mentally  excite  such  patients,  but  even  greater  mental  harm 
is  done  by  the  knowledge  that  their  heart  is  diseased  and 
the  conclusions  they  draw  from  it.  The  existence  of  a 
cardiac  lesion  or  of  heart  disease  is  still  generally  regarded 
even  by  educated  people  as  necessarily  leading  to  the  result 
that  the  patient  is  doomed.  This  opinion  is  altogether  in- 
correct in  the  large  majority  of  cases  of  heart  disease  if  the 
prophylactic  measures  described  in  the  preceding  pages  are 
carefully  and  thoroughly  carried  out.  This  erroneous  opinion 
produces  great  depression  which  reacts  unfavourably  upon 
the  patient  and  can  only  be  removed  by  a  physician  in  whom 
the  patient  places  the  fullest  and  most  immovable  confidence. 

It  is  difficult  to  describe  in  a  book  how  this  is  to  be  done. 
The  physician  has  to  point  out  again  and  again,  with 
caution  and  with  gentleness  but  also  with  earnestness  and 
emphasis,  that  a  "  lesion,"  a  "  weakness,"  is  not  yet  a 
"  disease,"  and  that  it  is  quite  possible  for  a  very  very  long 
time  to  get  on  perfectly  well  with  a  heart  whose  functional 
activity  is  reduced,  if  only  the  demands  made  upon  this 
vital  organ  are  not  greater  than  those  of  which  it  is  capable ; 
and  that  actual  serious  disease  arises  only  when  prophylactic 
measures  have  been  neglected  and  disregarded. 

We  should  be  cautious  too  in  the  use  of  such  ominous 
words  as  "  heart  lesion  "  or  "  fatty  heart,"  because  people 
are  apt  to  attach  a  very  serious  meaning  to  them.  "When 
the  physician  has  made  a  definite  and  exact  diagnosis  it  is 
his  duty  to  explain  to  the  patient  as  fully  as  is  possible 
what  is  the  condition  of  the  heart.  This  knowledge  will 
save  the  patient  from  all  unnecessary  fear  which  an 
erroneous  opinion  about  his  condition  might  cause  him,  and 
will  also  save  him  from  the  anxiety  of  feeling  that  he  does 

175 


THE  PBEVENTION  OP  DISEASE 

not  know  what  things  are  wrong  and  injurious  for  his 
condition,  and  it  is  therefore  of  the  greatest  possible  pro- 
phylactic value  against  mental  distress. 

How  one  will  give  such  explanations  and  instruction 
to  the  individual  patient  and  how  much  it  is  well  to  say- 
will  depend  entirely  upon  the  character  and  temperament 
of  the  patient.  The  difficult  task  of  the  physician  is  to 
distinguish  between  the  characters  of  different  patients, 
and  to  paint  the  disease  and  its  probable  course  in  some- 
what dark  colours  to  the  thoughtless  and  indifferent,  to 
point  out  the  possible  consequences  of  neglecting  to  follow 
medical  advice,  and  the  risks  and  dangers  which  such 
neglect  entails.  On  the  other  hand  he  must  inspire  hope  and 
confidence  in  the  anxious  and  timid  patient,  allaying  his 
anxieties  and  painting  the  picture  in  brighter  colours.  Two 
results  will  simultaneously  be  brought  about  by  such  wise 
treatment  of  a  patient  who  places  implicit  confidence  in  the 
physician  :  the  patient  will  carry  out  carefully  the  various 
instructions  given  him  for  the  prevention  of  heart  disease  and 
will  at  the  same  time  be  carrying  out  the  mental  prophylaxis. 

OCCUPATION 

The  choice  of  an  occupation  is  an  important  matter  when 
we  have  to  protect  the  heart  from  being  overstrained  by 
bodily  or  mental  exertion.  It  is  obvious  that  an  individual 
with  valvular  disease  of  the  heart  or  with  a  heart  whose 
functions  are  not  perfectly  normal  should  avoid  every 
vocation  which  would  necessitate  great  muscular  exertion 
or  much  bodily  activity.  Heavy  work  of  every  kind  is 
injurious.  An  easy  sedentary  quiet  occupation  requiring 
little  active  exertion  should  be  chosen  ;  and  the  heart's 
functional  activity  must  be  carefully  exercised  up  to  its 
full  limit  but  never  beyond  it,  by  regular  walking  and 
other  methods  already  described.  In  the  mode  of  life 
(sitting,  writing),  the  dress  (uniform)  and  other  conditions 
everything  is  to  be  carefully  avoided  which  by  compression 
would  tend  to  hinder  the  circulation.  These  precautions  are 
the  more  necessary  when  +he  heart  affection  has  developed 
late  in  life  ;  all  severe  muscular  exertion  should  at  once  be 

176 


THE  PREVENTION  OF  DISEASES  OF  THE  HEART 

stopped,  and  though  in  the  majority  of  cases  it  is  very 
difficult  yet  the  patient's  occupation  must  be  changed  and 
adapted  to  the  new  circumstances. 

"When  the  heart  muscle  is  affected  any  lifting  of  heavy 
weights  and  especially  any  sudden  strain  must  be  most 
carefully  avoided.  The  heart  is  no  longer  able  to  adapt 
itself  to  great  variations  in  the  demands  made  upon  it, 
and  is  most  seriously  injured  by  such  efforts.  It  is  well 
known  that  even  moderate  overstrain — the  running  after 
a  tramcar  or  an  effort  involving  some  slight  strain  or 
pressure  as  in  defecation — may  suffice  to  stop  the  heart's 
action  and  lead  to  sudden  death. 

The  same  is  true  of  mental  excitement.  Vocations  which 
involve  much  mental  excitement  should  be  avoided.  Here 
too  theory  is  easier  than  j)ractice  ;  no  vocation  is  altogether 
free  from  mental  emotion,  but  speculating  on  the  stock 
exchange  or  lecturing  should  not  be  chosen  as  occupations 
by  one  who  has  heart  disease. 

MARRIAGE 
Marriage  is  the  vocation  of  the  woman.  It  will  remain 
so  however  much  women  may  in  the  future  study  medi- 
cine. Indeed  when  women  have  received  a  thorough 
scientific  training  they  will  recognize  that  the  division 
of  occupation  between  the  two  sexes  as  seen  today  has 
developed  as  the  outcome  of  differences  in  organization  of 
the  two  sexes  and  not  through  any  arbitrary  action  of 
the  "  stronger  "  sex,  and  that  such  differences  must  there- 
fore always  exist.  A  woman  who  has  heart  disease  does 
not  thereby  become  necessarily  unfitted  for  marriage.  The 
opinion  of  the  physician  is  often  asked  on  this  question, 
and  it  is  by  no  means  always  easy  to  answer.  The 
decision  must  rest  essentially  upon  the  two  kinds  of  ex- 
cessive demands  which  will  be  made  upon  the  heart, 
namely  sexual  life  and  pregnancy  which  both  react  upon 
the  heart.  There  is  no  doubt  that  these  two  factors  may 
in  some  cases  act  very  injuriously  upon  the  heart,  even 
when  the  pregnancy  runs  a  normal  course  and  the  social 
conditions  of  the  patient  enable  every  care  to  be  taken. 

177  N 


THE  PEEVENTION  OF  DISEASE 

This  is  often  seen  in  the  course  of  medical  experience. 
Here  again  we  see,  what  pathology  is  so  constantly  show- 
ing us,  that  the  organism  can  adapt  itself  to  changes  of 
condition  which  come  on  slowly  and  gradually  but  cannot 
respond  to  sudden  great  changes  when  its  functional 
activity  is  no  longer  perfect,  and  that  one  such  great 
sudden  overstrain  may  suffice  to  cause  a  permanent  injury. 
In  view  of  the  possibility  of  one  or  more  pregnancies 
cardiac  insufficiency  is  not  a  contra-indication  to  marriage 
provided  the  woman  is  otherwise  well  developed,  and  that 
with  proper  care  fair  cardiac  compensation  is  possible.  In 
these  cases  women  may  pass  through  several  labours  and 
completely  recover.  The  case  is  different  to  that  of  pul- 
monary tuberculosis,  and  C.  Gerhardt  has  recently  pointed 
out  most  emphatically  that  pulmonary  tuberculosis  is 
always  a  contra-indication  to  marriage. 

The  matter  is  somewhat  different  in  the  case  of  the 
sexual  excitement  which  marriage  brings  with  it  in  greater 
or  less  degree  according  to  the  temperament  and  individu- 
ality of  the  partners  of  the  marriage.  Here  one  single 
excessive  demand  made  upon  the  heart — in  men  as  well 
as  in  women — may  be  extremely  serious,  especially  when 
it  is  oft  repeated  or  is  excessive  in  degree.  It  is  well 
known  that  sudden  death  has  not  seldom  occurred  during 
coitus,  because  the  sexual  act  so  greatly  increases  the  blood 
pressure  that  the  heart  fails.  When  any  one  who  has  a 
heart  affection  marries  the  physician  should  advise  the 
amount  of  moderation  necessary.  This  aspect  of  prophy- 
laxis requires  naturally  great  tact  on  the  part  of  the 
physician. 

In  other  cases  marriage  may  sometimes  act  very  favour- 
ably upon  the  heart  condition.  For  not  rarely  marriage 
may  prove  a  "  haven  of  rest."  When  marriage  will  lead 
to  more  stable  and  better  conditions  of  life,  when  marriage 
will  bring  with  it  the  possibility  of  better  care  and  better 
nourishment,  then  it  is  to  be  recommended,  though  the 
advantages  and  disadvantages  of  the  new  condition  should 
be  very  carefully  weighed. 

178 


THE  PREVENTION  OF  DISEASES  OF  THE  HEART 

INSTITUTIONS    FOR   THE   TREATMENT  OF   HEART 
DISEASE 

In  regard  to  a  suitable  abode  for  those  wbose  hearts 
require  special  care  the  general  social  conditions  are  un- 
fortunately such,  that  only  a  very  small  number  of  these 
patients  are  in  a  position  which  allows  them  to  select  the 
place  they  would  like  and  that  suits  them  from  the  point 
of  view  of  the  requirements  of  their  health.  However 
this  is  not  absolutely  essential  in  cases  of  heart  disease, 
we  need  only  shield  such  patients  from  the  injurious  effects 
of  climate,  especially  upon  the  organs  of  respiration,  which 
would  disturb  the  pulmonary  circulation  and  so  disturb 
and  render  more  difficult  the  work  of  the  heart.  Windy 
localities  must  therefore  be  avoided.  It  is  this  that  makes 
elevated  localities  not  well  borne  by  those  suffering  from 
heart  disease,  and  probably  when  the  right  side  of  the  heart 
is  no  longer  effi.cient  the  rarefied  air  and  low  atmospheric 
pressure  of  elevated  places  make  the  heart's  action  in- 
adequate. It  is  best  certainly  that  these  patients  should 
spend  the  hot  summer  in  the  mountains  not  in  a  town, 
but  a  spot  of  medium  elevation  should  be  chosen,  for  there 
they  feel  best.  The  temperature  should  be  cool  rather 
than  warm,  because  difficult  breathing  is  considerably 
relieved  by  a  cool  or  even  a  cold  atmosphere,  but  obviously 
great  care  must  be  taken  to  prevent  catarrh  of  the  respir- 
atory passages.  A  southern  mild  climate  is  necessary 
only  when  there  is  catarrh  or  congestion  of  the  lungs. 
The  seaside  is  also  very  good  and  useful  as  a  place  of 
residence.  Indeed  there  are  no  very  precise  indications  as 
to  climate.  All  depends  upon  the  individual's  power  of 
adapting  himself  to  circumstances.  In  fact  it  may  be  said 
that  any  medium  climate  is  suitable  and  offers  a  good 
prospect  to  one  with  heart  disease. 

The  most  essential  point  in  connexion  with  heart  pro- 
phylaxis is  the  necessity  of  allowing  all  possible  measures 
to  act  for  a  long  time  and  in  combination.  This  is  possible 
to  the  fullest  extent  only  by  residence  at  an  institution 
specially  adapted  for  the  purpose  and  fitted  up  with  every- 

179 


THE  PREVENTION  OF  DISEASE 

thing  wliicli  is  required  in  the  prophylaxis  of  heart  disease. 
The  tendency  of  medicine  is  more  and  more  to  treat  special 
classes  of  diseases  in  places  where  the  many  different 
applications  and  methods  which  are  required  can  be  used 
simultaneously  and  to  their  full  extent,  and  where  all  the 
indispensable  appliances  and  helps  are  at  hand.  It  is  only 
necessary  to  mention  sanatoria  for  diseases  of  the  lungs, 
where  just  as  an  artist  in  his  studio  himself  personally 
carries  out  every  part  of  his  work  till  it  is  finished,  the 
physician  not  only  advises  as  to  the  measures  to  be  adopted, 
but  watches  too  the  actual  carrying  out  of  the  treatment, 
or  rather  himself  carries  it  out.  Faust  rightly  sets  aside 
the  maxim  "in  the  beginning  was  the  word,"  and  replaces 
it  by  "  in  the  beginning  was  the  act."  So  too  in  the 
treatment  of  disease  we  should  endeavour  ourselves  to  do 
for  the  patient  all  that  we  possibly  can,  and  not  rest  content 
with  merely  giving  him  advice  which  will  be  forgotten 
or  neglected. 

The  establishment  of  institutions  for  the  treatment  of 
heart  disease  is  therefore  an  urgent  need  for  the  future. 
It  will  be  necessary  to  establish  such  institutions,  not 
only  for  the  richer  members  of  society,  but  also  for  the 
other  classes  of  the  population.  These  institutions  would 
be  of  greatest  service  in  the  prevention  of  those  injurious 
effects  which  result  from  the  improper  mode  of  life  of 
patients  who  require  to  be  careful  because  of  the  condition 
of  the  heart.  Here  the  patients  would  learn  how  thej'' 
ought  to  live,  and  later  on  returning  home  and  going  back 
to  their  vocations  would  take  with  them  the  knowledge 
which  they  have  acquired  of  the  necessary  prophylaxis. 
This  knowledge  would  not  then  rest  upon  verbal  instruc- 
tions and  teaching  only,  but  upon  previous  practice  to 
which  they  would  have  become  so  accustomed  that  it  had 
set  up  a  habit  which  they  would  continue  to  follow  almost 
unconsciously  and  involuntarily  for  the  rest  of  life.  A 
man  who  has  once  been  a  Prussian  soldier  will  have  ac- 
quired a  bearing  and  a  gait  and  many  other  bodily  actions 
which  he  will  retain  during  the  rest  of  his  life,  and  he 
will  unconsciously  repeat  them  in  the  way  in  which  he 

180 


THE  PEEVENTION  OF  DISEASES  OF  THE  HEART 

acquired  and  practised  them  ;  so  too  will  a  patient  who 
lias  stayed  long  enough  in  an  institution  for  the  treatment 
of  heart  disease  have  acquired  a  habit  of  prophylaxis 
which  will  be  of  the  greatest  benefit  for  the  rest  of  his 
life. 

In  the  therapeutics  of  heart  disease  such  an  institution 
would  do  for  all  classes  of  the  population  even  more  than 
what  today  the  various  "  watering  places  "  do  for  the  few 
patients  who  are  able  to  afford  to  go  to  them.  For 
example,  carbonic  acid  baths  are  exceptionally  valuable 
and  efficacious  in  the  treatment  of  heart  disease  ;  the  reason 
why  we  have  not  described  them  here  is  that  they  belong 
to  therapeutics  rather  than  to  prophylaxis.  In  addition 
to  the  baths  the  many  other  useful  prophylactic  measures 
in  force  at  these  places  are  also  of  the  greatest  therapeutic 
value — all  the  bodily  and  mental  factors  are  present, 
especially  the  necessary  rest  and  the  exclusion  of  all  busi- 
ness matters.  In  special  institutions  for  diseases  of  the 
heart  this  could  all  be  carried  out  even  more  perfectly,  and 
still  greater  success  would  result  from  the  treatment  of 
these  cases  than  is  possible  at  the  present  time  in  these 
public  "  bathing  places." 

There  are  numbers  of  people  whose  feeble  bodies  make 
them  unfit  for  the  social  conditions  in  which  they  live. 
Government  and  society  should  endeavour  to  provide 
work  and  occupation  for  these  of  a  kind  which  is  suitable 
for  their  reduced  physical  strength.  From  the  standpoint 
of  political  economy  it  is  absolutely  foolish  that  hundreds 
of  sufferers  from  heart  disease  are  employed  as  masons  and 
locksmiths  because  no  one  takes  any  trouble  in  the  matter. 
They  pass  a  wearisome  existence,  their  work  often  inter- 
rupted by  illness  and  their  life  considerably  shortened, 
while  many  others  of  great  physical  strength  are  em- 
ployed in  such  easy  occupations  as  horticulture  or  office 
work.  How  this  is  to  be  done  is  not  for  me  to  say,  but 
all  our  prophylactic  and  therapeutic  measures  can  only  be 
of  permanent  good  to  the  individual  when  their  entire 
mode  of  life  and  their  work  are  adapted  to  their  needs,  and 
this  is  the  main  factor  in  all  prophylaxis  and  therapeutics. 

181 


THE  PREVENTION  OF  DISEASE 

First  of  all  there  is  need  for  institutions  for  the  treatment 
of  heart  disease  ;  and  next  there  is  no  less  need  for  arrange- 
ments and  organizations  to  provide  for  the  patients  who 
leave  these  institutions  conditions  of  life  in  which  it  is  at 
least  possible  for  them  to  continue  the  prophylaxis  necessary 
in  their  case.  To  establish  such  institutions  is  the  first 
essential,  to  make  arrangements  for  suitable  conditions  of 
life  for  discharged  patients  whose  strength  has  been  im- 
proved is  the  second. 

CLOTHING 

With  regard  to  the  clothing  there  are  two  essential  con- 
ditions for  prophylaxis  in  cases  where  the  heart's  functional 
activity  is  below  the  normal.  First,  it  is  of  the  utmost 
importance  to  prevent  all  pressure  by  the  dress.  The 
commonest  and  most  injurious  form  of  such  compression  is 
that  produced  by  unsuitable  corsets  in  women;  for  a 
patient  suffering  from  heart  disease  should  never  wear  a 
corset.  Compression  acts  injuriously  in  two  ways :  it 
may  directly  interfere  with  the  heart's  movements,  or  it 
may  make  the  circulation  of  blood  at  the  more  remote  parts 
of  the  body  more  difficult.  The  corset  produces  both  these 
effects,  it  directly  compresses  the  lower  part  of  the  thorax, 
and  reduces  the  size  of  the  space  required  by  the  heart  in 
its  contractions ;  it  forces  the  diaphragm  and  liver  down- 
wards and  compresses  the  abdomen,  and  so  indirectly  ob- 
structs the  circulation  of  the  blood.  The  rest  of  the  dress, 
whichever  part  of  the  body  it  covers,  must  also  be  such  as 
not  to  constrict  or  press  upon  any  part ;  attention  is  especi- 
ally to  be  directed  to  the  collar,  waistband  and  garters. 
The  whole  dress,  of  whatever  kind  it  may  be,  should  be 
made  to  cover  the  body  loosely,  but  nowhere  be  closely 
fitting,  because  even  a  small  amount  of  pressure  is  injurious 
in  heart  disease.  Moreover  the  dress  should  be  light  in 
weight,  made  of  a  supple  material  to  prevent  respiration 
from  being  made  more  difficult,  particularly  during  exer- 
cise. It  is  very  much  a  question  of  the  cut  and  make-up, 
for  the  clothes  should  be  so  adjusted  that  they  are  not  felt 
as  a  weight  on  any  part  of  the  body. 

182 


THE  PREVENTION  OF  DISEASES  OF  THE  HEART 

The  second  requirement  is  tliat  the  dress  of  those  -who 
have  heart  disease  should  be  warm,  though  at  the  same 
time  not  thick  or  heavy.  Excess  in  warmth  must  be 
avoided  ;  and  the  dress  must  not  be  too  thick,  otherwise  it 
will  cause  excessive  perspiration.  These  patients  must  how- 
ever constantly  and  continuously  be  protected  against  a 
chilling  of  the  skin,  otherwise  the  cutaneous  vessels  will 
contract  too  greatly  and  cause  increased  work  for  the  heart, 
which  might  have  been  avoided  by  suitable  clothing. 

FOOD  AND  DRINK 

Food  exercises  a  most  important  influence  upon  the 
course  of  a  disease,  and  even  more  upon  the  strength  of  the 
organism  and  upon  its  metabolism  ;  this  is  so  universally 
recognized  that  we  need  not  enter  into  further  details. 
While  emphasizing  this  important  value  of  food  neverthe- 
less it  is  not  possible  to  draw  up  any  special  rules  and 
dietary  for  each  separate  form  of  disease.  In  this  connec- 
tion often  too  little  stress  or  none  at  all  is  laid  upon  the 
individual  conditions  of  absorption  and  assimilation  in 
health  and  in  disease.  Yet  all  depends  entirely  upon  this 
and  not  upon  any  "  nitrogenous  equilibrium,"  not  upon 
any  abstract  theories  about  the  relative  nutritive  values  of 
foods,  nor  upon  the  heat  value  of  foods,  which  have 
apparently  been  determined  to  be  necessary  under  certain 
conditions,  but  which  are  not  universally  applicable.  All 
these  theories  omit  the  fact  of  the  existence  of  great 
di£Perences  in  the  power  of  assimilation  of  different  indi- 
viduals, and  further  the  conditions  under  which  these 
experiments  have  been  made  were  unusual — as  Rosenbach 
well  puts  it — the  conditions  are  different,  and  it  is  quite 
impossible  that  the  food  suitable  for  a  strong  working 
man  in  full  work  is  that  which  is  required  by  a  patient 
in  a  hospital  leading  a  perfectly  inactive  life.  This  would 
indeed  imply  that  the  food  required  by  a  man  engaged  in 
carrying  heavy  loads  is  the  same  as  that  required  by  an 
attendant  in  a  museum. 

I  have  elsewhere  referred  to  this  subject  in  an  address 
in  which  I  drew  a  not  unsuitable  analogy  from  the  growth 

183 


THE  PREVENTION  OF  DISEASE 

and  development   of   a  child.      Obviously  for    the   proper 
assimilation   of  food,  it  is  essential  that  there  be  a  suffici- 
ent quantity  of  food,  with  its  constituents  in  the  proportions 
and  of  the  nature  in  which  assimilation  is  quickest  and  most 
easy  for  the  organism ;  but  from  this  it  does  not  follow 
that   the  amount  absorbed  by  all  is  identically  the  same. 
If,  for  example,  one  were  to  take  six  children  of  the  same 
age,  if  possible  even  of  the  same  body  weight  and  so  far  as 
possible  of  the  same  apparent  constitution,  and  were  to  feed 
each  on  exactly  the  same  amount  and  kind  of  food,  never- 
theless in  the  course  of  a  short  time,  though  none  of  them 
had   suffered  from   any   intercurrent    disease    or    unusual 
circumstance,  it   would   be   found    that    the   weights  and 
bodily  condition  of  these  six  children  would  all  differ  con- 
siderably one  from  another.      The  individual  constitutions 
were  different.     Such  individual   constitution  is  the  chief 
factor   in  the   development   of  disease;  just  as  the  factor 
which  we    term   the  power  of    resistance   may  determine 
whether  an  infective  disease,  when  the  infective  matter  is 
present,  shall  develop  or  not.       So    too  another  very  im- 
portant factor  in  the  constitution  is  the  individual's  power 
of  assimilation  which   determines   whether  in   any   given 
case  a  certain  definite  amount  of  food  will  maintain  the 
balance  and  replace  loss  by  metabolism,  or  whether  it  will 
be  an  insufficient  quantity  or  an  excessive  quantity  of  food. 
However  a   few   valuable   guiding   principles  can  be   laid 
down  as  to  the  food  suitable  for  patients  with  heart  disease. 
Omitting   for  the  moment   the  kind  of  food  and  even  its 
total  quantity,  it  is  most  important  to  regulate  the  way  in 
which  the  food  is  taken  and  the  amount  of  food  taken  at 
a  time.     I  have  described  the  technique  of  dietary  in  Von 
Leyden's  "  Textbook  on  the  Therapeutics  of  Diet,"  and  have 
laid  down  the  physiological  results  of  the  different  ways  of 
taking  food,  and  I  refer  the   reader   to   that   work.       For 
patients  with  heart  disease  the  most  essential  point  is  that 
the  food  shall  be  taken  in  a  way  which  will  not  increase 
the  work  of  the  heart.      As  is  the  case  with  tight  clothes, 
so  here  the  freedom  of  action  of  the  heart  may  be  interfered 
with  by  a  direct  limitation  of  its  movements ;  for  when  the 

184 


THE  PREVENTION  OF  DISEASES  OF  THE  HEART 

stomacli  is  overfilled  it  reduces    the  space  in   which,    the 
heart  can  move  in  the  same  way  as  pressure  from  without. 

The  amount  of  food  which  may  be  taken  at  a  time  is 
different  in  individual  cases,  and  sometimes  even  a  com- 
paratively small  amount  of  food  is  too  much.  Patients 
with  heart  disease  require  food  often,  and  only  a  little  at  a 
time,  to  prevent  any  over  filling  of  the  stomach,  and  they 
must  be  very  moderate  in  the  use  of  food  which  tends  to 
cause  flatulence  and  in  the  use  of  aerated  waters. 

Another  way  in  which  the  circulation  may  be  impeded 
is  by  food  which  is  difficult  of  digestion  because  it  is  close 
and  hard  ;  the  gastric  functions  may  be  so  greatly  increased 
thereby,  as  to  cause  a  large  flow  of  blood  to  the  digestive 
organs  and  so  to  increase  the  work  of  the  heart. 

For  these  reasons  stress  must  be  laid  upon  the  necessity 
of  sufficiently  masticating  food  and  upon  the  teeth  being  in 
good  condition.  The  patients  should  always  eat  leisurely, 
slowly  chewing  and  swallowing  their  food.  Care  must  be 
taken  also  to  vary  the  food  as  far  as  possible  ;  the  disinclina- 
tion of  such  patients  for  food,  and  especially  for  meat  and 
milk  which  are  so  valuable  as  food,  makes  it  very  difficult  in 
practice  to  supply  an  adequate  amount  of  food.  When  hot 
meat  is  not  taken  in  sufficient  quantity,  let  cold  meat  be 
substituted ;  there  is  often  less  objection  to  cold  meat,  and 
even  in  ordinary  life  we  can  eat  larger  quantities  of  cold 
meat  than  of  hot.  When  the  quantity  taken  is  still  insuffi- 
cient, the  meat  should  be  given  cut  up  small  or  minced. 
Preserved  meats  of  various  kinds  may  also  be  very  useful 
as  a  change,  and  especially  caviare  and  oysters.  Eggs  also 
should  be  given  in  every  possible  form.  Patients  with 
heart  disease  in  the  stages  for  which  the  prophylactic 
measures  mentioned  above  are  most  valuable  generally 
take  food  fairly  well ;  and  we  must  again  emphasize  the  fact 
that  patients  with  heart  disease  require  to  take  sufficient 
good  food  in  addition  to  observing  all  the  precautions  which 
have  been  laid  down.  They  must  not  take  any  excess  of 
food  which  only  fattens  them  and  produces  digestive  dis- 
turbances— but  short  of  this,  they  must  take  sufficient  food 
to  repair  the  wear  and  tear  of  the  tissues. 

185 


THE  PREVENTION  OF  DISEASE 

In  the  prophylaxis  of  heart  disease,  it  is  seldom  necessary 
to  have  recourse  exclusively  to  fluid  diet,  but  if  the  neces- 
sity arises,  beef  tea  and  other  liquid  foods,  white  of  egg  dis- 
solved in  water,  and  especially  milk,  should  be  given. 
When  ordinary  food  is  eaten  the  amount  of  liquid  taken 
must  be  limited.  It  is  not  necessary  to  go  so  far  as  Oertel 
does  and  stop  all  fluids ;  for  when  the  patient  is  forbidden 
to  drink  at  meals,  it  is  often  found  that  he  eats  much  less 
solid  food.  All  the  various  "  cures  "  for  obesity  are  based 
upon  one  and  the  same  principle,  of  preventing  the  patient 
from  eating  much ;  but  the  methods  employed  dijBfer. 
When  drinking  is  forbidden  at  meals  even  a  healthy 
person  is  soon  satisfied.  Still  the  fact  is  undeniable  that 
no  drop  of  fluid  leaves  the  body  without  having  passed 
through  the  circulatory  system  and  having  thus  increased 
the  quantity  of  fluid  in  circulation  ;  and  if  much  fluid  is 
quickly  ingested  the  vessels  are  much  overfilled  for  a  time, 
the  blood  pressure  raised  considerably,  and  the  heart  bur- 
dened with  an  excessive  and  injurious  amount  of  work. 
It  is  necessary  therefore  that  the  patient  should  take 
liquids  in  moderate  quantities  at  a  time ;  and  if  thus 
properly  divided  up,  two  to  three  pints  a  day  may  very 
well  be  allowed,  which  is  the  normal  quantity  also  for  a 
healthy  person. 

It  is  not  a  matter  of  indifference  what  form  of  liquid  is 
taken.  Milk,  broth,  cocoa,  chocolate,  lemonade,  the  juice  of 
fruits,  non-aerated  mineral  waters,  and  even  light  wines 
may  be  taken ;  concentrated  forms  of  alcohol  especially 
when  hot,  are  to  be  forbidden.  Though  beer  may  in 
some  cases  be  permitted  it  must  not  be  regarded  as  a  suit- 
able beverage  ;  when  it  is  taken  only  a  little  of  the  lighter 
form  of  beer  should  be  permitted,  and  effervescent  beers 
must  be  carefully  avoided.  Tea  and  coffee  if  taken  at  all 
must  be  well  diluted  with  milk  ;  the  measurement  of  the 
cardiac  stimulation  caused  by  them  will  be  a  guide  in 
special  cases.  The  same  holds  good  for  strong  wines.  They 
should,  as  mentioned  above,  be  excluded  from  the  patient's 
ordinary  diet,  though  they  may  occasionally  be  taken  with 
good  result,  but  rather  as  a  drug  than  as  a  food. 

186 


THE  PREVENTION  OF  DISEASES  OF   THE  HEART 

Prophylaxis  in  heart  disease  embraces  a  wide  scope  and 
consists  of  many  factors.  When  all  the  measures  briefly 
described  in  the  preceding  pages  are  carried  out,  a  patient 
whose  heart  has  through  predisposition  or  disease  under- 
gone some  loss  of  functional  activity,  may  for  a  long  time, 
often  up  to  the  normal  limit,  live  a  life  which  is  bearable, 
and  which  does  not  materially  deprive  him  of  the  enjoy- 
ments of  life  or  hinder  him  from  work,  provided  the  latter 
is  of  a  suitable  kind.  But  medical  directions  alone,  with 
however  great  detail  given,  will  but  seldom  make  such 
adequate  prophylaxis  possible  ;  in  this  respect,  the  most 
important  task  which  the  medical  profession  and  the  public 
authorities  have  before  them  is,  as  was  said  above,  the 
establishment  of  sanatoria  for  persons  with  heart  disease. 


187 


The  Prevention  of  the  Diseases  of  the 
Digestive  Organs 

BY 

DR.   MAX    EINHORN 

Professor  in  the  New  York  Post-Graduate  Medical  School 


189 


The   Prevention  of  the  Diseases  of  the 
Digestive  Organs 

GENEEAL    SECTION 

The  prevention  of  diseases  of  the  digestive  organs  in 
many  respects  coincides  with  the  prophylaxis  of  other 
diseases.  A  rational  mode  of  life,  in  accordance  with  the 
rules  of  hygiene,  is  of  the  greatest  importance.  To  enjoy 
good  health,  work  and  rest  must  go  harmoniously  hand  in 
hand.  In  the  civilized  world,  where  work  is  often  of  an 
intellectual  nature,  it  is  necessary  to  see  that  the  body  has 
sufificient  exercise.  An  incorrect  mode  of  life  with  regard 
to  eating  and  drinking  will  often  lead  to  harmful  results. 
Many  diseases  of  the  stomach  and  intestines  are  caused  by 
improper  food,  and  it  is  therefore  advisable  to  indicate 
briefly  what  should  be  done. 

Meals  should  whenever  it  is  practicable  be  taken  punctu- 
ally at  regular  hours.  The  time  given  to  a  meal  should 
not  be  too  short,  and  during  the  meal  the  body  should  be 
completely  at  rest,  physically  and  mentally,  and  no  thought 
be  given  to  business  matters  or  other  exciting  subjects. 
Some  pleasant  light  conversation  is  not  only  permissible 
but  is  good.  Food  should  be  taken  slowly,  and  well  masti- 
cated ;  liquids  too  must  be  taken  slowly  and  in  moderation. 
A  short  interval  between  the  courses  is  useful. 

The  number  of  meals  and  the  kind  of  food  at  a  meal 
may  best  be  left  to  the  customs  in  vogue  among  the  people. 
It  appears  to  me  however  to  be  desirable  to  point  out 
that  a  healthy  man  should  not  always  confine  himself  to 
food  which  is  very  easy  of  digestion.  On  the  contrary 
one  should  purposely  from  time  to  time  eat  food  which 

191 


THE   PREVENTION  OF  DISEASE 

is  less  easy  to  digest.  Every  other  organ  of  the  body  is 
strengthened  by  work,  and  in  the  same  way  the  digestive 
system  can  only  be  improved  and  strengthened  by  giving 
it  more  work  to  do.  People  who  endeavour  always  to  avoid 
indigestible  food  will  be  more  apt  to  get  indigestion  by 
eating  it  than  those  would  who  eat  indiscriminately  all 
that  is  put  upon  the  table. 

In  health  the  amount  of  food  taken  is  efficiently  regu- 
lated by  the  feelings  of  hunger  and  of  satiety,  but  at  a 
dinner  party  or  other  festive  gathering  the  appetite  may 
be  so  whetted  by  the  dainties  that  an  excessive  quantity  of 
food  is  taken,  and  one  should  remember  on  such  occasions 
not  to  overburden  the  stomach.  It  is  advisable  to  eat  only 
a  little  of  each  course,  or  to  omit  several  courses  altogether. 

After  meals  it  is  well  to  rest  for  a  short  time — a  quarter 
to  half  an  hour.  This  is  specially  necessary  after  the  chief 
meal,  and  many  people  are  accustomed  to  take  a  short  nap 
after  dinner.  If  the  sleep  is  only  a  short  one — not  exceeding 
half  an  hour — there  is  no  objection  to  it.  But  if  the  sleep 
is  permitted  to  last  one  or  two  hours,  it  is  decidedly  bad 
both  for  digestion  and  health. 

CONDIMENTS    AND   STIMULANTS 

Condiments  and  similar  substances  serve  to  whet  the 
appetite  by  stimulating  the  nerves  of  taste.  Upon  the 
whole  they  seem  to  exercise  a  favourable  influence  upon 
digestion.  Among  these  aids  to  appetite  are  spices  which 
are  added  to  food,  and  coffee,  tea  and  alcoholic  beverages. 
Food  should  be  made  palatable,  but  care  must  be  taken  not 
to  use  too  much  seasoning,  otherwise  the  digestive  organs 
are  soon  irritated  and  disease  produced. 

Tea  and  coffee  are  generally  taken  with  meals  or  shortly 
after.  The  object  of  both  is  to  counteract  the  feeling  of 
fatigue  and  sleepiness  which  sets  in  soon  after  a  meal.  It 
is  well  to  add  sugar  and  milk  to  the  coffee,  and  thus  make 
this  beverage  also  a  food.  In  moderation  tea  and  coffee 
are  not  followed  by  any  bad  effects,  but  are  useful.  If 
however  they  are  taken  in  excess,  they  certainly  lead  to 
digestive  and   to   nervous  disorders.     Restless  nights  are 

192 


DISEASES  OF  THE  DIGESTIVE  ORGANS 

often  caused  by  a  strong  cup  of  coffee  taken  late  at  night. 
In  excess  coffee  may  produce  disturbances  of  the  stomach 
and  intestines,  and  sometimes  cause  diarrhoea.  The  exces' 
sive  use  of  tea  may  cause  constipation. 

In  the  history  of  all  civilized  peoples  we  find  that  alcohol 
was  in  use.  Sometimes  it  was  the  juice  of  the  grape, 
sometimes  mead  or  beer,  and  sometimes  one  or  other  of  the 
many  forms  of  spirit,  such  as  cognac,  arrack  and  rum.  The 
antiquity  and  the  long  survival  of  this  custom  of  taking 
alcoholic  drinks  tend  to  show  that  they  have  some  use. 
As  is  generally  known,  these  drinks  act  as  stimulants. 
They  increase  the  bodily  strength,  enliven  the  mind,  and 
help  to  produce  a  feeling  of  cheerfulness  and  of  well-being. 
It  is  also  known  that  all  alcoholic  beverages  taken  in  excess 
lead  to  serious  organic  disease ;  it  is  therefore  evident  that 
all  excess  must  be  avoided.  The  more  concentrated  forms 
of  alcoholic  drinks,  such  as  brandy  and  the  heavy  wines, 
seem  to  be  the  most  injurious.  Light  table  wines  and  beer 
less  often  cause  disease.  Total  abstinence  from  alcoholic 
drinks  is  unnecessary ;  indeed  it  is  in  many  respects  dis- 
advantageous. In  advanced  age  and  in  most  conditions  of 
exhaustion,  alcoholic  liquids  are  regarded  as  valuable  aids 
for  strengthening  the  body.  To  prevent  the  production  of 
diseases  by  alcohol,  these  beverages  should  be  taken  only 
in  moderation.  One  should  be  careful  therefore  never  to 
exceed  a  given  amount ;  and  it  is  moreover  advisable  to 
drink  only  at  table  and  occasionally  in  the  evening  in 
company,  but  not  to  drink  with  friends  at  all  hours  of  the 
day. 

Although  this  habit  of  constant  drinking  should  be 
entirely  avoided,  it  is  not  necessary  to  make  any  absolute 
rule  in  the  matter.  On  festive  occasions  it  may  be  per- 
mitted to  take  somewhat  more  than  usual.  Such  enjoy- 
ments, if  only  indulged  in  occasionally  and  moderately,  add 
to  the  value  of  life. 

Among  the  luxuries  of  modern  life  must  also  be  reckoned 
the  use  of  tobacco.  Smoking  of  cigars,  cigarettes  and  pipes 
should  always  be  in  moderation.  There  is  no  doubt  that 
smoking  in  excess  brings  with  it  evil  results.     It  causes  not 

193  0 


The  prevention  of  disease 

only  functional  disturbances  of  the  heart,  but  also  digestive 
troubles.  Severe  colic  and  obstinate  diarrhoea  are  often  due 
to  abuse  of  tobacco  and  cannot  be  cured  until  the  smoking 
is  discontinued.  How  much  one  may  smoke  without  bad 
results  is  not  easy  to  determine  ;  it  depends  very  much  upon 
individual  peculiarities.  Many  men  are  always  smoking, 
and  yet  reach  old  age  without  feeling  any  ill  effects  from 
their  misuse  of  tobacco.  Others  again  suffer  from  tobacco 
poisoning  if  they  smoke  two  or  three  light  cigars  a  day. 
The  use  of  tobacco  is  a  luxury  and  of  no  special  advantage, 
and  we  would  therefore  counsel  growing  youths  not  to 
accustom  themselves  to  the  habit.  The  pleasure  which 
smoking  gives  will  not  be  missed  by  one  who  has  never 
smoked.  Smokers  should  be  advised  to  smoke  only  at  cer- 
tain hours  in  the  day,  and  to  use  tobacco  in  moderation. 
Directly  after  meals  is  the  best  time  for  smoking.  It  is 
hardly  necessary  to  add  that  light  cigars  are  preferable 
to  strong  cigars,  because  the  latter  contain  a  much  larger 
proportion  of  nicotin.  In  America  the  custom  of  chewing 
tobacco  is  very  common,  especially  among  the  lower  classes. 
By  this  method  the  tobacco  is  brought  into  close  contact 
with  the  mucous  membrane  of  the  mouth  and  cheeks,  and 
the  nicotin  is  quickly  absorbed,  and  therefore  obviously 
symptoms  of  tobacco  poisoning  appear  earlier  than  after 
smoking.  This  is  a  fact,  and  it  would  be  a  valuable  pro- 
phylactic measure  to  do  away  with  this  evil  custom. 

The  natural  instinct  with  regard  to  sexual  enjoyment 
may,  in  so  far  as  it  exists,  be  satisfied.  But  excesses  lead 
to  general  conditions  of  weakness  and  to  nervous  disorders 
of  the  digestive  apparatus.  The  golden  rule  here,  as  in  so 
many  other  matters,  is  the  happy  medium.  Although  for 
the  prevention  of  digestive  troubles  it  would  be  safer  to 
abstain  altogether  from  many  enjoyments,  such  as  drinking 
and  smoking,  yet  we  do  not  advise  absolute  prohibition  of 
tobacco  and  alcohol. 


194 


DISEASES  OF  THE  DIGESTIVE  ORGANS 


The  Prevention  of  Digestive   Disorders  in  the 
Course  of  other  Diseases 

The  rules  given  above  are  mainly  for  prophylaxis  against 
digestive  troubles  in  healthy  individuals.  It  is  now  neces- 
sary to  refer  to  the  prevention  of  gastro-intestinal  disorders 
in  the  course  of  other  diseases.  The  first  essential  in  acute 
diseases  should  be  to  take  precautions  to  spare  the  digestive 
apparatus.  The  acute  stage  is  generally  of  short  duration, 
and  no  harm  will  result  from  restricting  the  diet  for  a  short 
time.  The  diet  should  be  small  in  amount,  and  should  con- 
sist of  food  which  is  most  easy  of  digestion,  and  preferably 
liquid  food.  But  if  the  acute  illness  lasts  more  than  one  or 
two  weeks,  or  if  a  patient  already  very  weak  is  attacked 
by  an  acute  illness,  more  food  must  be  given  earlier,  and 
moreover  it  should  be  as  easy  of  digestion  as  possible. 
During  convalescence  after  acute  illness  the  change  to 
ordinary  food  must  be  made  very  slowly  and  cautiously, 
because  after  the  acute  illness  the  appetite  is  very  keen, 
and  if  left  to  his  own  inclinations  and  unwarned  the  patient 
is  very  apt  to  eat  impropsr  food  which  will  set  up  other 
troubles  in  the  digestive  tract. 

A  weakened  body  is  always  a  favourable  soil  for  the 
development  of  most  pathological  conditions,  and  the  fore- 
most and  most  important  task  in  prophylaxis  is  to  restore 
strength  to  the  weakened  body.  This  can  be  done  chiefly 
by  a  suitable  diet,  and  it  will  not  be  superfluous  here  to 
state  the  fundamental  principles  of  dietetics  which  are  so 
important  in  relation  to  those  who  have  been  weakened  by 
chronic  disease. 

Two  important  facts  have  been  discovered  during  recent 
years  of  the  greatest  significance  in  the  treatment  of 
patients  suffering  from  gastric  trouble,  and  they  have  in- 
fluenced considerably  the  entire  field  of  dietetics.  The  first 
fact  discovered  (by  von  Noorden  and  others)  was  that  the 

195 


THE  PEEVENTION  OF  DISEASE 

emaciation  in  chronic  diseases  of  the  stomach  is  not  the 
result  in  a  large  majority  of  cases  (if  not  in  all)  of  poisons 
circulating  in  the  blood,  but  is  entirely  the  result  of  in- 
sufficient ingestion  of  food.  On  the  other  hand,  by  analogy 
drawn  from  animal  and  vegetable  life,  where  if  any  one 
organ  is  injured  or  removed  some  other  allied  organ  takes 
on  the  function  of  the  injured  organ  and  vicariously  does 
the  work,  it  seemed  probable  that  when  serious  disturbance 
in  gastric  digestion  was  present  the  intestines  might  do 
the  work  instead.  That  this  is  a  fact  has  now  been 
experimentally  and  clinically  proved ;  several  observers 
(Leube,  Ewald  and  von  Noorden)  have  made  observations 
and  found  that  in  cases  of  atrophy  of  the  gastric  mucous 
membrane  where  the  gastric  secretion  has  completely 
ceased,  patients  may  nevertheless  keep  up  their  weight. 
My  own  work  on  achylia  gastrica,  that  is  absence  of  gastric 
secretion,  shows  that  these  patients  can  get  on  perfectly 
well  without  gastric  juice  ;  indeed  if  they  follow  a  suitable 
plan  they  may  even  increase  in  weight  and  live  the  full  limit 
of  life  without  suffering  any  trouble  :  that  is  to  say  when 
the  chemical  functions  of  the  stomach  are  entirely  lost,  the 
intestines  may  completely  carry  out  these  functions. 

These  two  facts — (1)  that  the  emaciation  in  chronic  gastric 
disease  rests  upon  insufficient  ingestion  of  food,  and  (2)  that 
even  in  serious  disorders  of  the  gastric  functions  the  in- 
testines may  act  vicariously  and  perform  all  the  work  of 
digestion — are  of  fundamental  importance  in  dietetics.  It 
is  therefore  evident  that  the  chief  aim  in  the  feeding  of 
patients  must  be  to  give  them  a  sufficient  quantity  of  food. 

As  the  substances  needed  to  maintain  life  in  patients 
suffering  from  digestive  troubles  are  not  less  in  amount 
than  those  required  under  normal  conditions,  they  will 
probably  require  to  take  (1)  as  large  a  quantity  of  food, 
(2)  the  same  kinds  of  food,  as  under  normal  conditions. 
The  only  possible  difference  will  be  the  choice  among  the 
variety  of  foods  and  the  choice  as  to  the  form  and  prepara- 
tion of  the  food. 

The  digestibility  of  a  food  depends,  firstly  upon  its  form 
and   consistence,  secondly  upon  the   amount   of   nutritive 

196 


DISEASES  OF  THE  DIGESTIVE  ORGANS 

matter  which  it  contains.  "  Corpora  non  agunt  nisi  fliiicla," 
is  an  old  axiom,  and  the  following  table  of  foods,  drawn  up 
mainly  according  to  their  conditions  as  liquids  or  solids, 
ranges  the  foods  according  to  their  digestibility. 

1.  Most  digestible  are  foods  in  the  fluid  form— either  (ci) 
fluids  :  milk,  meat  juice,  broth,  beef  extracts,  solutions  of 
peptones,  toast  water,  mucilaginous  decoctions,  rice  water, 
oyster  soup,  solutions  of  white  of  egg  ;  (6)  substances  which 
become  liquid  at  the  temperature  of  the  body  :  jellies,  fruit 
jellies,  ice  cream,  fruit  ices. 

2.  Broths :  foods  cut  up  very  small  and  well  cooked  in 
water;  soup  in  the  form  of  broth  (barley  soup,  oatmeal, 
semolina,  rice,  sago),  egg  soup,  Leube's  meat  essence, 
pounded  meat,  powdered  biscuits  in  milk,  water  or  broth, 
koumiss,  skim  milk,  cream  and  butter. 

3.  Foods  which  are  easily  broken  up  by  stirring  in 
water:  white  bread  in  milk  or  water,  the  tops  of  well- 
cooked  asparagus,  carrots,  mashed  potatoes,  baked  potatoes, 
hard  boiled  yolk  of  egg,  and  oysters. 

4.  Solid  foods :  white  bread,  rye  bread,  meat,  hard-boiled 
eggs,  fish  and  cheese. 

5.  Substances  very  difficult  of  digestion :  meat  of  coarse 
fibre,  lobsters,  sausages,  and  Swiss  cheese.  All  substances 
containing  much  cellulose,  especially  when  they  are  eaten 
raw :  vegetables,  salads,  cucumbers.  Uncooked  fruits : 
apples,  pears,  pineapples.  Fruits  containing  much  acid, 
namely,  all  unripe  fruits,  strawberries.  Substances  which 
contain  mach  sulphur,  and  thus  tend  to  cause  flatulence  : 
all  forms  of  cabbage,  especially  white  cabbage,  beans. 

This  list  is  arranged  on  theoretical  principles,  and  for  the 
most  part  accords  with  the  opinion  founded  on  experience, 
and  by  this  experience  I  am  generally  guided. 

To  prevent  insufficient  food  being  taken  by  the  patient, 
it  is  best  not  to  forbid  any  food  except  such  as  we  know  to 
be  directly  injurious  to  the  patient,  and  to  let  the  patient 
have  a  large  variety  of  food. 

With  regard  to  the  number  of  meals  and  the  times  for 
meals,  it  is  best  not  to  make  any  change  unless  there  is 
some  special  indication  for  it. 

197 


THE  PEEVENTION  OF  DISEASE 

There  are  many  prejudices  against  certain  foods,  both 
among  the  public  and  among  medical  men.  For  example 
fat  and  butter  were  formerly  strictly  forbidden  in  all 
dyspeptic  conditions.  But  fat  is  one  of  the  food-stuffs 
which  possesses  the  [greatest  value  as  a  heat-producer,  and 
butter  moreover  is  not  a  bulky  form  of  food.  Fat  which  is 
not  rank  passes  through  the  stomach  without  affecting  it 
at  all,  and  is  digested  in  the  intestine ;  there  is  therefore 
no  ground  for  withholding  butter,  and  indeed  it  should  be 
strongly  recommended.  Bread  and  other  carbohydrate  food 
is  often  forbidden  or  its  use  restricted  for  fear  that  it  will 
cause  fermentation.  Even  though  it  be  true  that  carbo- 
hydrates readily  give  rise  to  fermentation,  yet  the  cases  in 
which  much  fermentation  occurs  in  the  stomach  are  fairly 
rare,  and  it  only  occurs  when  food  is  delayed  in  the  stomach 
for  a  very  considerable  time.  The  adult  consumes  daily, 
according  to  Konig,  f  pound  to  1^  pounds  of  bread,  and 
60  to  60  per  cent,  of  his  total  food  and  50  to  75  per  cent, 
of  his  carbohj'-drate  food  is  taken  in  the  form  of  bread. 
This  shows  plainly  how  valuable  bread  is,  and  the  use 
of  it  should  generally  be  recommended.  It  is  usually  said 
that  bread  crust,  stale  bread  and  biscuits  are  more  easily 
digested  because  a  larger  proportion  of  the  starchy  material 
they  contain  has  been  converted  into  dextrose.  Although 
I  think  that  new  bread  should  be  avoided,  yet  I  seldom  find 
any  great  difference  in  the  ease  with  which  patients  digest 
crust  and  the  other  parts  of  well-baked  white  bread. 

The  use  of  stimulants,  such  as  wine,  beer,  coffee  and  tea, 
may  generally  be  permitted  as  occasion  necessitates,  but 
they  must  be  taken  in  moderation  and  in  a  suitable  form. 
Strong  spirits  and  spices  should  be  avoided. 

Substances  to  promote  appetite  are  beneficial,  especially 
if  directly  indicated  ;  a  little  caviare,  some  sardines  or 
anchovies  can  be  given  with  bread  or  a  biscuit  a  quarter 
of  an  hour  before  a  meal  time. 

These  principles  are  applicable  to  all  cases  of  chronic 
disease,  whether  of  the  digestive  system  or  of  any  other 
organ,  as  in  tuberculosis,  in  diseases  of  the  heart,  kidney, 
liver  or  spinal  cord. 

198 


DISEASES  OF  THE  DIGESTIVE  ORGANS 


The  Prevention  of  Diseases  of  the  Stomach 

GASTRIC    CATARRH 

Acute  gastric  catarrh  may  be  best  prevented  by  avoiding 
errors  in  diet,  sucli  as  overloading  the  stomach,  ingestion 
of  improperly  cooked  or  decomposed  food  and  ice-cold 
drinks.  Eating  too  quickly  and  swallowing  large  un- 
masticated  pieces  of  food  should  also  be  carefully  avoided. 

Chronic  gastric  catarrh  may  be  best  prevented  by  care- 
fully treating  acute  gastric  catarrh,  and  not  allowing  it  to 
pass  into  a  chronic  condition  ;  and  by  avoiding  everything 
which  tends  to  cause  chronic  gastric  catarrh.  One  should 
not  eat  too  quickly,  should  well  masticate  the  food  before 
it  is  swallowed,  and  not  overload  the  stomach  with  large 
quantities  of  food.  Highly  seasoned  dishes  and  ice-cold 
drinks  irritate  the  stomach  and  may  produce  a  catarrhal 
condition.  Iced  water  and  eating  too  fast  are  the  two  chief 
causes  of  the  so-called  "  American  dyspepsia."  Tea  and 
coffee  taken  in  excess  can  also  give  rise  to  chronic  gastric 
catarrh.  Alcoholic  drinks,  especially  the  stronger  kinds, 
such  as  whisky,  liqueurs,  and  "  bitters,"  and  the  excessive 
use  of  tobacco,  by  smoking  and  more  particularly  by 
chewing,  may  also  cause  gastric  catarrh. 

In  addition  to  suitable  dieting,  the  patient  should  lead  a 
rational  healthy  life.  Business  hours  should  not  be  too  long ; 
and  sufficient  bodily  exercise  should  be  taken.  Walking 
or  driving,  riding,  cycling  and  rowing  should  be  strongly 
recommended  ;  but  care  must  be  taken  not  to  overstrain 
the  body.  Gymnastic  exercises  at  home  are  also  useful, 
say  for  ten  minutes  every  morning.  A  cold  bath  in  the 
morning,  and  thorough  friction  with  a  thick  rough  towel 
are  valuable.  Moreover  the  patient  should  live  in  well 
ventilated  rooms,  and  be  forbidden  to  stay  long  in  smoky 
places  and  restaurants. 

199 


THE  PREVENTION  OF  DISEASE 


GASTEIC   ULCEE 


Yon  Sohlern  lias  pointed  out  tliat  in  many  districts 
!  where  the  inhabitants'  diet  consists  chiefly  of  vegetables 
■^  gastric  nicer  is  unknown.  A  vegetable  diet  is  very  rich 
in  potassium  salts,  for  it  contains  about  a  third  more  than 
does  a  mixed  diet ;  and  as  the  red  blood  corpuscles  are  the 
chief  carriers  of  potassium,  Von  Sohlern  thinks  that  the 
greater  amount  of  potassium  salts  in  their  food  confers 
immunity  against  gastric  ulcer  on  the  inhabitants  of  these 
districts.  For  these  theoretical  reasons.  Von  Sohlern  re- 
commends the  administration  of  potassium  salts  and  of 
foods  rich  in  vegetable  substances  as  a  prophylactic  against 
gastric  ulcer. 

Certain  occupations  greatly  predispose  to  ulcer  of  the 
stomach,  and  in  cases  of  gastric  ulcer  these  occupations 
should  be  avoided.  Cooks  often  suffer  from  gastric  ulcer, 
and  the  tasting  of  very  hot  food  has  often  been  thought  to 
be  the  cause.  Cooks  should  therefore  be  cautioned  and 
advised  to  let  the  food  cool  before  they  taste  it.  Shoe- 
makers are  said  often  to  suffer  from  gastric  ulcer,  most 
probably  from  the  bent  position  of  the  body  assumed  in 
their  occupation.  It  is  advisable  therefore  to  hold  the 
body  as  upright  as  possible  when  at  work. 

Chlorosis  and  anaemia  are  important  factors  in  the 
causation  of  gastric  ulcers,  and  it  is  therefore  important  to 
treat  these  disorders  at  the  very  beginning,  and  remove 
the  condition  favouring  the  development  of  gastric  ulcer. 
Excess  of  hydrochloric  acid  is  very  often  met  with  in 
gastric  ulcer,  and  it  is  highly  probable  that  this  is  favour- 
able to  the  development  of  an  ulcer.  This  excessive  forma- 
tion of  hydrochloric  acid  therefore  should  be  treated. 

Grastric  ulcer  is  often  accompanied  by  serious  complica- 
tions, haematemesis  and  perforation  being  the  most 
i  dangerous.  It  seems  desirable  here  to  say  a  few  words  with 
regard  to  the  prevention  of  these.  A  strict  diet  is  of  first 
importance,  it  should  be  liquid  or  semi  liquid,  and  all 
indigestible  and  highly  seasoned  food  should  be  avoided  ; 
and  next  in  importance  is  the  avoidance  of  severe  bodily 

200 


DISEASES  OF  THE  DIGESTIVE  ORGANS 

movements,  siicli  as  riding  and  golf.  When  the  haemor- 
rhage is  of  frequent  occurrence,  it  may  be  advisable  to  think 
of  performing  a  gastro-enterostomy  in  order  that  the 
gastric  contents  may  more  rapidly  be  passed  on  into  the 
intestine,  and  the  surface  of  the  ulcer  be  thus  to  some 
extent  relieved  from  irritation.  This  operation  is  often  of 
great  value  in  preventing  recurrence  of  haemorrhage,  and 
moreover  it  may  lead  directly  in  some  cases  to  recovery. 


EEOSIONS    OF  THE    STOMACH 

In  a  large  number  of  cases  of  erosion  of  the  stomach,  a 
chronic  catarrh  coexists  and  seems  to  be  the  cause  of  the 
erosion.  The  prophylactic  measures  which  are  best  for 
preventing  erosions  are  those  which  prevent  the  chronic 
gastric  catarrh. 

CAECINOMA    OF    THE    STOMACH 

The  cause  of  cancer  is  not  yet  known,  it  is  therefore 
scarcely  possible  to  state  how  it  may  be  prevented.  "VVe 
can  merely  name  a  few  of  the  factors  which  are  said  to 
play  a  part  in  the  aetiology  of  cancer,  and  say  how  they 
are  possibly  to  be  avoided.  Some  accident  was  formerly 
regarded  as  definitely  a  cause  of  the  development  of  cancer 
of  the  stomach.  Of  late  this  opinion  has  been  much  em- 
phasized by  Boas.  It  is  advisable  therefore  that  all  blows 
upon  the  abdomen  be  avoided.  During  recent  years  many 
authorities  have  stated  that  cancer  is  more  frequent  among 
the  upper  classes,  who  live  well  and  eat  much  meat,  than 
among  the  poorer  classes.  If  such  be  the  case,  care  should 
be  taken  to  live  less  luxuriously  and  to  eat  less  meat. 
According  to  Eichorst  and  Cloquet  the  frequent  consump- 
tion of  cider  and  of  sour  wines  is  said  to  favour  the 
development  of  cancer.  Another  matter  should  also  receive 
attention.  As  Eosenheim  has  shown  that  cancer  sometimes 
develops  upon  the  site  of  an  ulcer,  it  is  advisable  that 
every  effort  should  be  made  to  heal  an  ulcer,  in  order  to 
prevent  the  formation  of  a  cancer. 

201 


THE  PREVENTION  OF  DISEASE 


HYPEECHLOEHYDEIA    AND    HYPEESECEETION 

Sorrow  and  anxiety  and  mental  overwork  must  be 
strictly  forbidden.  All  highly  seasoned  food,  strong 
alcoholic  beverages  and  iced  water  must  be  avoided.  These 
causes  all  contribute  greatly  to  the  development  of  hyper- 
chlorhydria,  that  is  the  excessive  formation  of  hydrochloric 
acid,  and  hypersecretion.  "When  hyperchlorhydria  is  already 
present,  every  possible  means  should  be  taken  to  prevent 
the  disorder  from  getting  worse.  The  daily  life  of  the 
patient  must  then  be  regulated  with  reference  to  the 
amount  of  work  he  does,  bodily  exercise,  mental  rest  and 
amusements.  "What  suits  one  does  not  suit  another,  and  it 
is  therefore  necessary  to  treat  each  patient  individually. 
Business  men  upon  whom  great  responsibilities  rest,  lawyers, 
politicians  and  physicians  must  be  taken  away  from  their 
work  and  sent  into  the  country  in  order  to  allow  the  brain 
to  rest  from  the  strain  for  a  time.  Ladies  in  high  circles 
of  society  who  frequent  all  social  functions  must  adopt  a 
quiet  life.  There  are  others  again  possessing  much  pro- 
perty and  having  no  occupation  who  get  ill  merely  because 
they  devote  too  much  attention  to  their  bodily  functions, 
and  it  becomes  necessary  to  find  some  mental  occupation 
for  them.  Sponging  the  body  all  over  with  cold  water 
every  morning,  and  bodily  exercise  for  about  eight  or  ten 
minutes  on  rising  are  valuable  in  most  cases.  The  patient 
should  be  advised  to  take  a  walk  once  or  twice  a  day  for 
half  to  one  hour,  or  to  ride,  drive,  or  cycle. 

ACHYLIA   GASTEICA 

Gastric  atrophy  can  only  rarely  be  prevented.  Chronic 
gastric  catarrh  which  has  existed  a  long  time  passes  into 
atrophy.  Careful  treatment  of  the  gastric  catarrh  is  there- 
fore often  serviceable  as  a  prophylactic  against  the  develop- 
ment of  atrophy.  G-eneral  nervous  conditions  must  be 
carefully  treated  by  the  usual  measures,  so  that  these  pre- 
disposing conditions  for  atrophy  may  be  removed.  There 
are   however  cases   in  which  gastric  atrophy  has  existed 

202 


DISEASES  OF  THE  DIGESTIVE  ORGANS 

so  long   tliat   we   have   to   look   upon   it  as   a  congenital 
abnormality.     In  such  cases  no  prophylaxis  is  possible. 

DILATATION    OF    THE    STOMACH 

Acute  dilatation  of  the  stomach  can  bs  prevented  by 
avoiding  all  errors  in  diet  and  overloading  of  the  stomach. 

Chronic  dilatation  of  the  stomach  may  result  from  various 
causes :  (1)  stenosis  of  the  pylorus  ;  (2)  hypertrophy  of  the 
pylorus ;  (3)  distention  and  muscular  weakness  of  the 
stomach.  Stenosis  of  the  pylorus  may  be  caused  by  non- 
malignant  as  well  as  by  malignant  new  growths.  Pre- 
vention of  stenosis  of  the  pylorus  can  have  reference  only 
to  the  non-malignant  forms,  and  these  are  for  the  most  part 
due  to  the  development  of  scar  tissue  after  an  ulcer  has 
healed  For  these  reasons  the  ulcerative  process  must  be 
very  carefully  treated  while  still  recent,  and  treatment 
should  be  continued  till  the  ulcer  has  permanently  healed. 
As  soon  as  there  are  symptoms  of  a  commencing  ulcer  a 
fluid  diet  must  be  adopted  and  continued  for  a  long  time, 
in  order  to  prevent  any  severe  irritation  of  the  spot.  The 
region  around  the  ulcer  near  the  pylorus,  which  becomes 
irritated  and  inflamed,  will  thereby  be  more  easily  restored 
to  its  normal  condition.  The  cause  of  simple  hypertrophy 
of  the  pylorus  is  not  yet  understood,  and  its  prophylaxis  is 
therefore  impossible.  Prophylaxis  of  malignant  stenosis  of 
the  pylorus  is  similar  to  that  for  cancer  of  the  stomach. 
To  prevent  dilatation  of  the  stomach  from  weakness  of  the 
muscular  wall,  all  atonic  conditions  of  the  stomach  must 
be  treated  early  by  electricity,  massage,  and  general  gym- 
nastics, and  by  proper  diet.  The  imbibition  of  large 
quantities  of  fluid  should  also  be  avoided. 

TETANY 

Tetany  is  occasionally  a  complication  of  dilatation  of  the 
stomach.  It  can  only  be  prevented  by  not  permitting 
food  to  accumulate  in  the  stomach.  This  is  best  done  by 
giving  liquid  food,  by  washing  out  the  stomach,  and  by 
administering  drugs  which  check  fermentation.     Bouveret 

203 


THE  PREVENTION  OF  DISEASE 

and  Devic  have  shown  that  when  much  alcohol  is  taken 
more  toxic  products  are  formed  in  the  stomach  in  the 
presence  of  hydrochloric  acid ;  and  it  is  therefore  obvious 
that  to  prevent  tetany  alcohol  must  be  forbidden. 

ENTEEOPTOSIS 

Much  may  be  done  to  prevent  enteroptosis.  In  a  large 
number  of  cases  it  is  the  result  of  mechanical  action. 
Compression  of  the  lower  part  of  the  thorax  and  of  the 
upper  half  of  the  abdomen  pushes  the  organs  downwards. 
It  is  of  the  utmost  importance  that  women  should  not  wear 
corsets,  or  at  least  that  the  corsets  should  be  loose.  Tight 
clothes  round  the  waist  must  also  be  avoided.  Enteroptosis 
may  also  arise  from  rapid  changes  in  the  contents  of  the 
abdomen,  as  after  childbirth  or  the  removal  of  large  abdo- 
minal tumours.  In  these  cases  there  is  a  sudden  lowering 
of  abdominal  pressure,  and  organs  which  have  occupied  a 
higher  position  slip  down  to  fill  the  empty  space,  The  best 
means  of  preventing  enteroptosis  in  all  these  cases  are  rest 
in  bed  for  several  weeks,  and  the  use  of  suitable  abdominal 
belts  to  keep  the  abdominal  walls  in  position  and  reduce 
the  size  of  the  abdomen.  Enteroptosis  may  be  caused  also 
by  great  emaciation  and  inanition ;  and  attempts  should  be 
made  to  prevent  it  by  administering  nutritive  food.  It  is 
also  important  to  strengthen  the  abdominal  muscles  by 
gymnastic  exercises. 

NEEVOUS    AFFECTIONS    OF    THE    STOMACH 

Excessive  mental  exertion,  grief,  unusual  excitement 
and  sexual  excesses  are  the  chief  causes  of  neuroses  of 
the  stomach.  These  points  should  all  receive  attention. 
Several  neuroses  of  the  stomach  continue  or  become  worse 
by  constant  repetition,  for  example  nervous  eructations, 
regurgitation,  rumination  and  nervous  vomiting.  In 
such  cases  it  is  important  to  get  the  patient  to  suppress 
the  desire  to  bring  up  gases  and  food.  Habit  plays  a 
great  part  in  prophylaxis,  and  whenever  there  is  a  ten- 
dency to    these  disorders    the  patient  should    be    properlj^ 

204 


DISEASES  OF  THE  DIGESTIVE  ORGANS 

instructed  wliat  to  do.  In  neuroses  affecting  other  organs, 
general  treatment  is  required  to  prevent  the  development 
of  any  neurosis  of  the  stomach. 


The   Prevention   of   Diseases  of  the   Intestine 

ACUTE    AND    CHEONIC    INTESTINAL    CATAEEH 
To  prevent  acute  intestinal  catarrh  the  following  rules 
must  be  observed. 

1.  One  must  carefully  avoid  heavy  indigestible  food,  ice- 
cold  drinks,  tainted  meat  or  fish,  unripe  fruit,  stale  or  sour 
beer,  and  bad  water. 

2.  Excessive  ingestion  of  food  and  drink,  even  though 
wholesome,  must  also  be  forbidden. 

3.  Many  organic  and  inorganic  substances  which 
chemically  irritate  the  intestinal  mucous  membrane  and 
cause  inflammation  must  be  prescribed  as  seldom  as 
possible:  such  are  the  drastic  purgatives  like  croton  oil, 
colocynth  and  jalap ;  and  among  inorganic  substances, 
tartar  emetic,  arsenic,  lead,  copper  sulphate,  all  prepara- 
tions of  mercury,  concentrated  acids  and  strong  caustic 
alkalies. 

4.  Mechanical  irritation  by  faecal  masses,  gallstones, 
enteroliths ;  or  foreign  bodies  which  have  been  swallowed, 
as  large  fruit  stones  and  coins,  may  cause  inflammation. 

5.  Influences  of  temperature:  the  susceptibility  to 
changes  of  temperature  seems  to  be  very  different  in 
different  individuals.  Some  people  get  diarrhoea  if  they 
sleep  in  summer  without  much  bedclothes  and  the  tempera- 
ture happens  to  fall ;  others  by  getting  their  feet  wet. 

Chronic  intestinal  catarrh  arises  either  out  of  a  severe 
acute  enteritis  which  has  not  perfectly  subsided,  or  after 
repeated  attacks  of  acute  enteritis  in  rapid  succession  and 
before  the  intestine  has  had  an  opportunity  of  recover- 
ing completely.  This  often  occurs  in  patients  who  take 
but  little  notice  of  an  apparently  trivial  affection  and  do 

205 


THE  PEEVENTION  OF  DISEASE 

not  carry  out  the  physician's  instructions  about  diet.  The 
direct  causes  are  similar  to  those  of  acute  enteritis.  For 
prophylaxis  it  is  therefore  necessary  to  take  the  pre- 
cautions required  to  prevent  acute  intestinal  catarrh,  and 
moreover  to  treat  an  acute  intestinal  catarrh  carefully  and 
thoroughly  and  prevent  relapse.  In  regard  to  this  the 
following  is  important :  the  patient  should  wear  warm 
clothing,  especially  over  the  abdomen  (flannel  belt)  and  on 
the  feet,  and  take  care  not  to  get  wet  feet ;  in  rainy 
weather  shoes  with  thick  soles  or  goloshes  should  be  worn. 
"When  there  is  diarrhoea,  we  must  forbid  acid  and  sweet 
wines,  all  aerated  mineral  waters,  lemonade,  all  fruits, 
salads,  all  kinds  of  cabbage  and  cauliflower,  and  brown 
bread  and  pastry.  Instead  of  these  we  should  give  only 
eggs  (lightly  boiled  or  beaten  up),  tender  meat,  calf's  brain, 
chicken,  lamb  cutlets,  oysters,  light  fish,  well  baked  white 
bread  or  toast,  fresh  butter,  and  mucilaginous  soups,  meat 
broth,  rice,  sago,  macaroni,  mashed  potatoes  or  baked 
potatoes,  milk,  cocoa,  tea,  koumiss,  ginger  ale,  good  red 
wine,  or  tokay. 

All  food  must  be  taken  only  in  small  quantities  at  a  time  ; 
drinks  should  be  warm  or  cool  (at  the  temperature  of  the 
room),  but  not  cold.  "When  there  is  a  tendency  to  constipa- 
tion, light  fruits  may  be  taken,  such  as  oranges,  grapes,  or 
ripe  pears,  green  vegetables,  green  peas  and  cauliflower. 
The  addition  of  more  nutritive  foods,  easily  assimilated  fat, 
butter,  cream  and  liquids  will  bs  useful.  Indigestible 
food,  such  as  brown  bread,  Grerman  sausage,  lobster  salad, 
mayonnaise,  cabbage  and  cucumber  should  be  avoided. 
Beer,  porter,  or  Rhine  wine  in  moderate  quantities  may  be 
allowed. 

DYSENTEEY 

It  is  best  to  keep  away  from  those  latitudes  where 
dysentery  is  endemic.  In  epidemics  care  should  be  taken 
to  regulate  the  life  according  to  the  best  hygienic  principles. 
Food  should  be  taken  regularly,  as  hunger  or  want  of  food 
predisposes  to  this  disease.  Recent  investigations  show 
that  most  cases  of  dysentery  are  caused  by  invasion  of  the 

206 


DISEASES   OF  THE  DIGESTIVE  ORGANS 

body  by  amaeboe.  Tlie  latter  enter  tlie  body  mainly  with 
the  food  or  drink,  and  scrupulons  care  should  therefore  be 
taken  that  the  food  and  liquids  taken  are  absolutely  free 
from  contamination.  The  food  should  be  eaten  boiled  or 
roasted,  and  the  water  filtered  and  afterwards  boiled.  Raw 
fruit  and  salad  should  be  omitted  from  the  dietary.  Care 
must  be  observed  that  the  evacuations  of  dysenteric 
patients  do  not  contaminate  anything,  or  very  thorough 
disinfection  should  be  employed. 

INTESTINAL     ULCEES 

It  will  scarcely  be  possible  to  prevent  duodenal  ulcers. 
Upon  the  whole  the  indications  for  prophylactic  treatment 
are  similar  to  those  for  gastric  ulcer.  After  extensive 
burns  duodenal  ulcers  are  apt  to  form,  and  it  is  therefore 
necessary  to  keep  the  burnt  surface  carefully  dressed  and  as 
aseptic  as  possible. 

Tuberculous  ulcers  in  the  intestine  may  be  primary  or 
secondary.  To  prevent  primary  ulcers  care  must  be  taken 
that  the  flesh  of  tuberculous  animals  is  not  eaten,  nor  the 
milk  from  tuberculous  cows.  It  is  difficult  to  ascertain 
whether  the  milk  is  from  a  healthy  or  tuberculous  cow, 
and  it  is  therefore  very  advisable  to  boil  the  milk  regularly 
before  use.  Secondary  tuberculous  ulcers  occur  in  phthiscal 
patients  and  are  generally  caused  by  sputum  which  is 
swallowed  and  so  infects  the  bowel.  Phthisical  patients 
should  therefore  be  directed  never  to  swallow  their  sputum 
but  always  to  expectorate  it. 

Syphilitic  ulceration  of  the  intestines  is  best  prevented  by 
thorough  treatment  with  mercury  directly  the  first  signs 
of  syphilis  appear. 

Yery  little  can  be  done  to  prevent  lardaceous  disease  of 
the  bowel.    Conditions  of  malnutrition  should  be  avoided. 

NEW  GEOWTHS  OF  THE  INTESTINES 

New  growths  both  malignant  and  benign  in  the  intestine 
cannot  be  prevented,  because  we  are  at  present  completely 
in  the  dark  as  to  the  aetiology  of  these  tumours. 

207 


THE  PREVENTION  or  DISEASE 

HAEMOEEHOIDS 

All  conditions  wliicli  lead  to  permanent  hyperaemia  of 
the  lower  part  of  the  rectum  tend  to  cause  haemorrhoids. 
These  points  should  be  carefully  noted.  Occupations  which 
necessitate  prolonged  sitting  or  standing  should  be  avoided. 
Clerks,  students,  shoemakers,  tailors,  cavalrymen,  needle- 
women and  washerwomen  must  take  especial  care  against 
haemorrhoids.  Those  who  live  well  and  those  who  take 
highly  spiced  and  fatty  food  suffer  from  congestion  of  the 
portal  circulation  and  thus  are  predisposed  to  haemorrhoids ; 
such  patients  should  adopt  a  simpler,  more  suitable  mode  of 
life.  Habitual  constipation  and  the  use  of  strong  pur- 
gatives, such  as  aloes,  colocynth,  or  gamboge,  are  a  frequent 
cause  of  haemorrhoids,  and  this  must  be  borne  in  mind  in 
prophjdaxis.  Patients  who  are  predisposed  to  haemorrhoids 
should  observe  the  following  rules :  they  should  take 
plenty  of  exercise  in  the  open  air,  eat  little,  avoid  alcoholic 
or  venereal  excess,  and  see  that  the  bowels  are  daily 
evacuated.  If  there  is  any  tendency  to  constipation  the 
following  purgatives  are  useful — salines,  sulphur,  or  rhu- 
barb :  for  example  a  teaspoonful  of  the  compound  powder 
of  liquorice  every  evening,  or  a  teaspoonful  of  equal  parts  of 
flowers  of  sulphur  and  cream  of  tartar.  Rhubarb  in  the  form 
of  the  tincture  or  as  a  powder,  ten  to  fifteen  grains  twice 
daily,  is  useful  for  more  constant  use.  The  waters  of  Karlsbad, 
Kissingen,  Marienbad,  Tarasp  and  Saratoga  are  also  of 
use,  more  especially  when  taken  at  these  springs  in 
combination  with  a  suitable  diet.  With  regard  to  the  diet 
the  following  points  should  be  observed :  full  meals  should 
be  avoided,  and  food  taken  more  often  but  little  at  a  time. 
Fish,  well  cooked  fresh  vegetables  and  ripe  fruit  should 
compose  the  main  bulk  of  the  food.  Alcoholic  drinks,  strong 
coffee  and  highly  spiced  dishes  should  be  avoided.  The 
various  kinds  of  cheese,  very  coarse  brown  bread,  cabbage, 
peas  and  beans  are  best  omitted.  Salad,  potatoes,  carrots, 
spinach,  asparagus  and  cauliflower  are  permissible  in  small 
quantities  because  they  make  the  intestinal  contents  more 
liquid  ;  boiled  and  raw  fruit,  such  as  apples,  pears,  plums, 

208 


DISEASES  OF  THE  DIGESTIVE  ORGANS 

oranges  and  grapes  are  useful.  For  a  beverage  water  is 
best,  taken  between  meals,  rather  less  than  a  pint  at  a  time. 
In  some  cases,  especially  in  anaemic  conditions,  a  little 
skimmed  milk  may  be  given  instead  of  water.  A  small 
quantity  of  light  beer  may  be  permitted. 

APPENDICITIS 
Formerly,  as  a  prophylactic,  one  forbade  the  swallowing 
of  fruit  stones,  pieces  of  bone,  and  portions  of  indigestible 
food,  but  now   we  know  that  these  play  no  part  whatever 
in   the    production    of    appendicitis.      Regulation    of    the 
bowels  and  removal  of  constipation  were  also  regarded   as 
important  prophylactic  measures,  but  recent  investigations 
show  that  this   is   not  so.     Regulation  of   the   bowels    is 
important  and  to  be  recommended,  but  the  only  means  we        / 
possess  of  preventing  appendicitis  is  to  remove  the  appendix.      ^ 
This   cannot  be   recommended  in   all   cases,    because    the 
operation  is  not  quite  free  from  danger,  but  it  may  always 
be    undertaken  when  a  laparotomy  is  necessary  for  some 
other  reason  and  when  it  does  not  take  too  long. 

INTESTINAL    OBSTRUCTION 

Prophylactic  measures  against  acute  intestinal  obstruction 
are  only  possible  in  the  sense  that  all  conditions  should  be 
avoided  which  tend  to  produce  it.  AVe  should  take  care  that 
all  herniae  are  radically  cured  or  a  suitable  truss  applied.  If 
gallstones  are  present,  purgatives  should  be  used  to  prevent 
the  gallstone  from  becoming  impacted  and  causing  obstruc- 
tion. In  severe  chronic  constipation  intestinal  obstruction 
may  result  from  the  occlusion  of  the  lumen  of  the  intestine 
by  hard  faecal  masses.  In  these  cases  care  should  be  taken 
not  to  let  constipation  exist  for  long,  and  to  soften  the 
faecal  masses  if  they  have  become  hard.  In  constriction  of 
the  intestines,  acute  intestinal  obstruction  must  be  avoided. 
For  such  cases  mild  aperients  should  be  often  used,  and  all 
food  should  be  avoided  which  gives  rise  to  much  faecal 
matter  or  which  irritates  the  intestine.  Thus,  green  vege- 
tables, salad,  fruit,  vinegar,  mustard  and  pepper  should  be 
strictly  forbidden  ;  but  the  patient  may  take  milk,   milk 

209  p 


THE  PEEVENTION  OF  DISEASE 

soups,  eggs,  tender  meat  witliout  much  fat  and  without  any 
gristle,  butter,  toast,  or  well  baked  white  bread,  gruel,  rice, 
or  sago,  well  cooked.  Patients  should  eat  frequently  and 
not  too  much  at  a  time.  Cold  drinks  should  be  avoided. 
Care  must  be  taken  to  give  sufficient  food. 

DIAEEHOEA 

Diarrhoea  is  either  a  symptom  of  intestinal  catarrh,  or  is 
associated  with  abnormalities  of  the  functions  of  the  stomach, 
or  is  an  independent  purely  nervous  affection.  Prophylaxis 
of  intestinal  catarrh  has  already  been  described,  and  we 
need  only  refer  here  to  the  two  latter  forms.  To  prevent 
diarrhoea  which  occurs  in  connexion  with  abnormal 
conditions  of  the  stomach — "  dyspeptic  diarrhoea  " — the 
abnormal  condition  of  the  stomach  must  be  treated  as  soon 
as  it  is  diagnosed,  and  every  available  means  taken  to  cor- 
rect it.  To  prevent  nervous  diarrhoea,  it  is  necessary  by  the 
usual  means  to  strengthen  the  nervous  system  of  all  who 
are  predisposed  to  neurasthenia  or  to  any  nervous  disease. 

Bromides,  iron  and  arsenic  will  often  be  needed.  A 
sufficient  amount  of  food  must  be  taken  and  of  great  variety, 
and  the  bowels  must  be  made  to  act  regularly.  After  the 
bowels  have  acted  in  the  morning,  the  patient  should  not 
allow  them  to  act  again  unless  it  is  absolutely  unavoidable. 
Any  slight  desire  to  defaecate  should  be  suppressed. 

CONSTIPATION 

Habitual  constipation  is  in  many  cases  caused  by  re- 
peatedly neglecting  the  calls  of  nature.  Young  girls  at 
school  suppress  the  desire  to  defaecate  from  a  sense  of  false 
modesty,  and  this  leads  to  irregularity  in  the  action  of  the 
bowels  and  afterwards  to  constipation.  G-reat  punctuality 
should  be  observed  with  regard  to  this  act.  The  exhibition 
of  purgatives  for  slight  temporary  digestive  disturbances 
should  be  avoided  and  nature  should  be  allowed  to  act.  A 
patient  should  never  be  too  long  restricted  to  an  exclusive 
diet ;  exclusion  of  vegetables,  fruit  and  of  carbohydrates 
from  the  diet  often  leads  to  marked  constipation.  An 
hygienic  mode  of  life,  regular  habits,  less  strain  from  work, 

210 


DISEASES  OF  THE  DIGESTIVE   ORGANS 

less  worry  and  more  fresh  air  and  out-of-door  exercise  are  of 
the  greatest  value  in  preventing  constipation.  As  a  rule  I 
give  very  little  or  no  aperients.  "When  there  is  a  tendency 
to  slight  constipation  the  following  measures  will  be  found 
to  be  best :  one  should  drink  simple  cold  water  upon  an 
empty  stomach,  or  skimmed  milk,  take  grapes,  oranges,  and 
other  fruit,  raw  or  cooked,  such  as  apples,  plums,  pears  and 
peaches,  lemonade,  honey,  salmon,  sardines,  herrings,  plenty 
of  vegetables,  spinach,  green  peas,  cauliflower,  cabbage, 
salad,  rye  bread  and  butter.  One  should  avoid  strong  tea, 
red  wines,  bilberries,  cocoa  and  chocolate, 

METEORISM  OR  FLATULENCE 

This  affection,  when  not  produced  by  some  organic  ob- 
struction in  the  intestine,  is  caused  by  some  anomaly  in 
peristalsis  and  absorption.  For  the  former  cause  hardly 
anything  can  be  done  in  the  way  of  prophylaxis.  For  the 
latter  two  causes  the  following  points  should  be  observed  : 
one  should  avoid  taking  much  gas,  as  in  aerated  waters 
or  substances  which  give  rise  to  much  formation  of  gas, 
such  as  cabbage,  beans  and  peas,  and  large  quantities  of 
carbohjT-drates.  Care  should  be  taken  that  the  bowels  act 
regularly,  and  any  slight  tension  in  the  abdomen  should  be 
relieved  by  a  mild  aperient. 

INTESTINAL  PARASITES 

For  the  prevention  of  infection  by  intestinal  parasites 
the  following  measures  are  of  importance  :  (I)  The  hands 
should  be  kept  very  clean.  If  soiled  with  any  faecal 
matter,  and  after  touching  domestic  animals,  the  hands 
should  be  carefully  washed  and  possibly  a  disinfectant 
used.  (2)  All  meat  and  vegetables  should  be  well  cooked, 
or  exposed  to  a  sufficiently  high  temperature.  All  fruits 
and  salads  should  be  thoroughly  washed  before  being  put 
on  the  table.  (3)  Drinking  water  should  be  filtered  and 
boiled.  (4)  Navvies  and  brickmakers  should  wash  their 
hands  thoroughly  before  meals  and  on  leaving  work. 


211 


Prophylaxis  in  Surgery 

BY 

PROF.  A.  HOFFA 

OF  WiJEZBUEG 

AND 

DR.  A.  LILIENFELD 


213 


Prophylaxis  in   Surgery 

The  following  pages  are  a  presentment  of  one  aspect  of 
hygiene,  indeed  a  kind  of  clinical  hygiene.  In  reality, 
every  method  of  treatment  is  preventive,  since  from  the 
moment  that  the  patient  comes  into  our  hands  for  treat- 
ment, we  endeavour  to  prevent  further  mischief,  and 
to  remove  the  mischief  which  already  exists.  In  the 
special  department  of  surgery,  however,  there  is,  if  one  may 
say  so,  a  special  prophylactic  treatment.  In  every  case  we 
are  obliged,  Avhenever  it  is  at  all  possible,  to  act  conserva- 
tively ;  and  when  the  conservatism  is  not  possible  and 
operation  is  inevitable,  we  remove  as  little  as  possible  and 
adopt  the  safest  course  and  method  we  can.  All  the  great 
results  of  modern  surgery  are  the  outcome  of  prophylactic 
measures.  By  anaesthesia  we  prevent  the  patient  feeling 
pain  and  cause  relaxation  of  the  muscles ;  by  Esmarch's 
method  of  depriving  a  part  of  its  blood  supply,  haemor- 
rhage is  reduced  to  a  minimum,  and  by  aseptic  or  anti- 
septic treatment  of  wounds  we  guard  our  patients  against 
the  risk  of  infection.  In  other  ways  too  preventive 
treatment  plays  an  important  role  in  surgery,  and  we 
cannot  too  strongly  urge  the  surgeon  to  perfect  himself  in 
prophylaxis.  From  how  much  trouble,  for  instance,  he  can 
save  a  patient  if  he  treats  a  fracture  rightly  from  the  very 
beginning  ;  and  how  much  trouble  will  be  caused,  not  only 
to  the  patient  himself,  but  also  to  the  doctor  and  the 
accident  insurance  company,  when  the  injured  part  has  not 
healed  properly.  Such  accidents  and  their  results  have 
proved  to  us  how  much  formerly  was  lacking  in  the  treat- 
ment and  especially  in  the  after  treatment  of  such  injuries, 

215 


THE   PREVENTION  OE  DISEASE 

and  how  much  better  able  we  are  now  to  treat  these  cases 
correctly  from  the  very  beginning. 

We  have  endeavoured  in  the  following  pages  to  expound 
the  general  principles  according  to  which  preventive  treat- 
ment in  the  various  departments  of  surgery  should  be 
carried  out. 

A.    General   Prophylaxis 

I.    PEEVENTIVE  MEASUEES  IN  THE  PEfiFORMANCE 
OF  OPERATIONS 

The  report  of  Heimann  shows  that  569,576  patients  were 
treated  in  the  various  hospitals  of  Prussia  during  the  year 
1894 ;  and  that  58,988  patients  out  of  this  total  number 
underwent  serious  operations.  He  calculates  that  twelve 
per  cent,  of  the  total  number  of  deaths  occurring  in 
hospitals  were  after  operations.  These  figures  warn  us  that 
in  spite  of  all  advances  in  antisepsis  and  asepis,  and  in  spite 
of  all  improvements  recently  introduced  to  minimize  the 
risks  of  anaesthesia,  we  should  in  every  case  consider  very 
carefully  whether  all  the  indications  for  the  operation  are 
present,  and  we  should  constantly  keep  before  our  minds 
the  dangers  to  which  we  expose  our  patients  in  major 
operations.  The  nature  of  the  dangers  is  twofold,  some- 
times arising  from  threatened  infection,  at  other  times  from 
the  anaesthetic  itself.  One  of  the  noblest  aims  of  the 
surgeon  is  to  relieve  pain,  and  we  can  readily  understand 
the  enthusiasm  aroused  by  the  introduction  of  anaesthesia, 
as  described  by  Diffenbach  in  his  book,  "  Ether,  a  Preventive 
of  Pain."  Yet  this  must  not  blind  us  to  the  great  moral 
responsibility  which  we  take  upon  us  when  we  give  anaes- 
thetics. 

What  then  are  the  dangers  of  anaesthesia,  especially  of 
chloroform  anaesthesia  (that  anaesthetic  being  still  most 
frequently  used  in  Grermany)  and  how  can  we  prevent  these 
risks  as  far  as  possible  ? 

Every  time  an  anaesthetic  is  given  we  should  be  on  the 
lookout  for  acute  chloroform-asphyxia  with  its  manifold 
symptoms,  and  next  we  must  guard  against  its  after  effects. 
As  to  the  latter,  the  researches  of  Fraenkel,  Kindskopf  and 

216 


PROPHYLAXIS  IN  SURGERY 

others  have  shown  that  degenerative  changes  are  produced 
in  various  organs,  especially  in  the  kidneys  and  heart,  by 
the  toxic  action  of  chloroform.  In  patients  with  renal  or 
cardiac  disease  chloroform  must  be  administered  with  the 
greatest  caution,  or  some  other  anaesthetic  must  be  substi- 
tuted for  it.  "VVe  see  how  important  it  is  to  examine 
thoroughly  the  patient  before  giving  him  an  anaesthetic ; 
for  the  right  choice  of  an  anaesthetic  depends  chiefly  upon 
a  previous  careful  examination  of  the  heart,  the  lungs  and 
the  kidneys  :  in  this  way  only  can  we  hope  to  reduce  the 
risks  of  anaesthesia.  Valuable  though  chloroform  is,  yet 
we  should  always  regard  it  as  a  poison,  and  should  adminis- 
ter the  smallest  quantity  possible. 

During  the  last  few  years  certain  rules  have  been  drawn 
up  to  remove  the  direct  dangers  of  chloroform  narcosis,  and 
though  it  is  impossible  to  remove  all  the  dangers,  yet 
they  are  considerably  lessened  when  these  rules  are  care- 
fully followed. 

It  is  self  evident  that  the  anaesthetist  should  be  a  qualified 
medical  man,  and  this  is  expressly  required  by  law.  This 
regulation  is  unfortunately  not  always  obeyed  in  hospitals, 
and  the  responsibility  of  giving  an  anaesthetic  is  entrusted 
to  nurses,  though  it  is  a  duty  which  only  a  doctor  can 
rightly  perform..  The  custom  which  is  said  to  obtain  in 
England  of  allowing  unqualified  persons  to  give  chloroform, 
we  consider  most  reprehensible. 

The  various  stages  of  narcosis  will  now  be  considered, 
and  the  possible  dangers  which  may  supervene.  It  is 
absolutely  necessary,  when  circumstances  permit,  that  the 
patient  should  be  prepared  for  the  anaesthetic  by  emptying 
the  stomach  and  intestines.  For  some  hours  before  the 
anaesthetic  is  given  the  patient  should  have  no  food,  and 
the  bowels  should  be  emptied  by  a  purgative,  followed  if 
necessary  by  an  enema.  These  measures  suffice  in  many 
cases  to  remove  the  tendency  to  vomiting.  After  having 
had  a  warm  bath,  the  patient  is  placed  upon  the  operating 
table,  which  should  be  in  a  warm  room  (GS°  to  75°  F. 
according  to  the  nature  of  the  operation),  as  it  has  been 
proved  that  there  is  always  loss  of    body-heat  after  pro- 

217 


THE  PREVENTION  OF  DISEASE 

longed  anaesthesia.  Gas-jets  should  be  avoided  in  order  to 
prevent  the  formation  of  products,  especially  of  chlorine 
compounds,  which  affect  injuriously  the  respiratory  organs. 
The  patient  should  be  placed  in  the  horizontal  position. 
The  anaesthetist  should  ascertain  that  the  patient  has 
no  foreign  body  such  as  artificial  teeth  in  his  mouth, 
and  then  the  mask  should  be  applied,  but  so  as  to  admit 
free  access  of  air.  It  is  most  essential  to  use  as  little 
chloroform  as  possible  when  beginning  to  induce  narcosis, 
and  the  drop  method  now  so  universally  employed  is 
best.  The  chloroform  should  be  absolutely  pure  and  kept 
in  a  small  brown  stoppered  bottle  to  protect  it  from  light 
and  air,  and  should  be  given  by  the  drop  method,  about 
twenty  to  forty  drops  per  minute  being  used. 

One  of  the  first  symptoms  which  may  appear  is  the  so- 
called  "  stage  of  excitement "  in  those  who  have  been  addicted 
to  alcohol.  To  prevent  or  diminish  this,  it  is  best  to  give 
one  or  two  wineglasses  of  good  brandy  a  quarter  of  an  hour 
before  the  anaesthetic.  Injections  of  morphia  are  often 
used  to  prevent  this  stage  of  excitement,  but  the  after 
effects  may  be  very  bad,  and  we  do  not  therefore  recommend 
its  use ;  alchohol  however  seems  to  improve  the  action  of 
the  heart.  It  is  often  reported  that  sudden  fatal  syncope 
has  occurred  at  the  very  beginning  of  anaesthesia  when 
the  patient  had  had  only  a  few  whiffs.  Personally  we 
believe  that  these  cannot  all  be  ascribed  to  the  action  of 
the  chloroform,  but  that  a  large  number  of  these  deaths 
are  due  to  shock  through  fear  or  some  other  nervous  dis- 
turbance in  a  sensitive  ^Datient.  Once  we  had  a  death  upon 
the  operation  table  of  a  patient  who  had  a  small  empyema, 
and  who  died  at  the  moment  when  the  inhaler  was  about 
to  be  placed  over  his  face,  and  before  he  had  inhaled  any 
chloroform  vapour. 

A¥e  do  not  deny  that  cases  of  true  cardiac  syncope  occur 
very  suddenly  even  after  very  small  doses  of  chloroform, 
and  that  in  many  cases  we  are  powerless  to  prevent  it,  but 
it  seems  to  us  that  such  cases  are  not  very  numerous. 
These  cases  should  warn  us  to  watch  the  pulse  and  respira- 
tion very  carefully  from  the  very  commencement  of  giving  the 

218 


PROPHYLAXIS  IN  SURGERY 

anaesthetic,  and  we  must  liere  speak  against  tlie  erroneous 
opinion  that  the  heart  ceases  to  act  only  after  cessation  of 
the  respiration,  and  that  it  is  sufficient  therefore  to  watch 
the  respiration  only.  The  pulse  must  be  watched  from  the 
beginning,  and  at  the  same  time  observation  of  the  respira- 
tion must  not  be  omitted. 

Deep  anaesthesia  is  recognized  by  the  complete  absence  of 
the  corneal  and  conjunctival  reflexes  and  by  diminution  in 
the  size  of  the  pupils,  which  at  the  commencement  of 
anaesthesia  undergo'some  dilatation.  The  deeper  the  narcosis 
at  the  commencement  of  the  operation,  the  less  chloroform 
will  be  required  for  prolonged  operations.  But  this  is  the 
moment  when  the  anaesthetist  cannot  be  too  cautious,  and 
when  he  must  give  his  full  attention  to  the  slightest 
change  noticed  in  the  patient,  even  in  the  colour  of  the 
skin.  If  the  pulse  gets  worse  or  ceases  altogether,  the 
operation  must  be  interrupted  and  attemj^ts  must  be  made 
to  restore  the  action  of  the  heart.  One  should  see  that  the 
respiratory  tract  is  free,  and  should  push  forward  the  lower 
jaw,  or  still  better,  should  draw  forward  the  tongue  and 
apply  massage  to  the  heart  by  the  Koenig-Maass  method.  In 
this  way  it  has  often  been  possible  to  bring  the  patient  back 
to  life,  though  the  heart  has  ceased  to  beat  for  some  time. 

As  to  respiratory  difficulties,  it  is  always  possible  to 
remove  these  ;  indeed,  it  is  generally  possible  in  cases  of 
cardiac  syncope  which  end  fatally  to  keej)  the  respiration 
going  artificially  for  some  time  after  the  heart  has  ceased 
to  beat.  Above  all  we  must  keep  the  respiratory  tract  free 
from  any  obstruction.  Among  the  various  methods  of 
artificial  respiration  Schtiller's  is  the  best.  In  this  method 
the  right  and  left  arches  of  the  ribs  are  grasped  one  in 
each  hand,  and  are  forcibly  drawn  upwards  and  outwards, 
and  then  pressed  downwards  again  towards  the  abdominal 
cavity.  At  the  same  time  the  tongue  is  drawn  forward, which 
may  be  done  with  least  injury  by  pointed  bullet  forceps  ;  the 
upper  opening  of  the  larynx  must  first  have  been  cleared 
of  mucus.  By  observing  these  principal  precautions  we 
shall  be  able  to  reduce  the  number  of  deaths  from  chloro- 
form, a  considerable  number  of  which  still  occur.  According 

219 


THE  PREVENTION  OF  DISEASE 

to  Gurlt's  statistics  of  330,429  cases  of  cliloroform  anaesthe- 
sis,  there  was  one  death  from  cliloroform  to  every  2,076 
cases.  The  future  will  show  whether  it  is  possible  to  avoid 
all  chloroform  fatalities.  But  deaths  will  only  be  prevented 
if  the  anaesthetist  gives  his  undivided  attention  to  his 
important  task  ;  so  many  cases  which  are  in  great  part,  we 
think,  due  to  the  carelessness  of  the  anaesthetist,  may  then 
be  prevented.  But  the  main  point  is  that  only  a  medical 
man  should  administer  chloroform. 

After  what  has  been  said  we  shall  not  be  surprised  that 
in  recent  years  the  oldest  anaesthetic,  namely  ether,  has 
come  again  to  the  front  as  a  powerful  competitor  of  chloro- 
form. Gurlt's  statistics  of  1893  showed  that  only  one  case 
of  death  was  recorded  in  about  16,000  cases  of  anaesthesia 
by  ether ;  but  in  last  year's  report  the  proportion  of  deaths 
to  cases  was  1  to  6,112,  now  that  we  are  acquainted  also 
with  the  indirect  effects  of  ether.  Ether  has  an  unfavour- 
able effect  upon  the  respiratory  passages,  and  among  its 
after  effects  is  pneumonia,  which  in  weakly  patients  readily 
proves  fatal.  The  great  advantage  of  ether  over  chloro- 
form is  that  the  danger  to  the  heart  appears  to  be  far  less, 
and  it  is  the  unexpected  sudden  failure  of  the  heart  which 
we  have  chiefly  to  fear  with  chloroform,  and  which  we  are 
quite  unable  to  prevent.  An  unpleasant  symptom  of  ether 
is  the  secretion  of  a  large  amount  of  saliva  and  mucus,  and 
this  leads  to  unpleasant  respiratory  difficulties  much  more 
frequently  than  when  chloroform  is  used,  and  the  employment 
of  ether  in  phthisical  patients,  in  catarrh  of  the  respiratory 
passages,  and  in  the  young,  seems  contra-indicated.  The 
question  as  to  which  anaesthetic  is  the  least  dangerous  when 
we  consider  also  the  after  effects  is  not  yet  settled,  and  will 
probably  not  be  settled  for  many  years  to  come,  and  mean- 
while we  shall  still  be  obliged  to  use  both.  On  the  whole 
we  can  confirm  the  opinion  of  Ktimmell,  who  writes,  "  In 
the  present  state  of  our  knowledge  we  should  use  ether 
only  in  cases  with  heart  disease,  in  those  who  are  very 
weak,  and  when  during  anaesthesia  conditions  of  weakness 
become  apparent."  One  great  drawback  in  our  present 
method  of  anaesthesia  must  still  be  mentioned :  we  do  not 

220 


PROPHYLAXIS  IN   SURGERY 

yet  possess  any  convenient  apparatus  by  which  we  can 
measure  correctly  the  amount  of  chloroform  and  ether 
vapour  which  we  are  administering  to  the  patient,  and 
cannot  therefore  determine  the  exact  quantity  employed. 

To  speak  about  other  mixtures  now  in  use,  for  in- 
stance, Billroth's  mixture  used  in  Vienna,  and  the  A.C.E. 
mixture  employed  in  England,  would  take  too  long.  Neither 
can  we  go  into  the  question  of  other  anaesthetics  such  as 
bromethyl  and  pental,  which  are  rarely  used  in  surgical 
practice. 

Paralysis,  which  sometimes  appears  after  prolonged 
anaesthesia,  and  affects  especially  the  brachial  plexus,  can 
probably  always  be  avoided  by  supporting  the  upraised 
arm  and  by  suitable  posture. 

The  subject  being  so  very  important,  we  will  briefly 
recapitulate  the  preventive  measures  to  be  taken  in  every 
case  of  anaesthesia,  and  we  shall  follow  in  the  main  the 
rules  so  excellently  set  forth  by  Klimmell. 

1.  Chloroform  is  generally  to  be  preferred  for  the  anaes- 
thetic. With  patients  who  are  very  anaemic  or  exhausted, 
who  have  cardiac  disease  but  are  free  from  any  respiratory 
trouble,  ether  should  be  used  after  the  stage  of  unconscious- 
ness has  been  induced  by  chloroform.  "We  may  also  change 
to  ether  when  prolonged  anaesthesia  is  required  and  the 
heart's  action  is  becoming  weak  under  the  influence  of  the 
chloroform. 

2.  The  chloroform  or  ether  should  be  absolutely  pure  and 
kept  in  small  dark  bottles,  BO  grammes  of  chloroform  or 
200  grammes  of  ether  in  each,  protected  from  light  and  heat, 
and  should  be  used  out  of  the  bottle  itself. 

3.  Great  caution  is  needed  when  during  the  anaesthesia 
injections  of  morphia  are  employed ;  the  combination 
favours  the  development  of  respiratory  failure  during  the 
later  stages  of  narcosis.  On  the  other  hand,  it  is  an 
advantage,  especially  in  the  case  of  those  addicted  to 
alcohol,  to  administer  during  chloroform  anaesthesia  larger 
or  smaller  quantities  of  alcohol. 

4.  The  kidneys,  lungs  and  heart  should  be  examined 
before  giving  an  anaesthetic. 

221 


THE  PREVENTION  OF  DISEASE 

5.  Anaesthesia  should  be  induced  in  a  perfectly  quiet 
room,  the  j)atient  being  in  the  horizontal  posture  with  the 
head  low.  All  manipulations  before  the  patient  is  under 
the  influence  of  the  anaesthetic  should  be  avoided. 

6.  The  anaesthetist  should  be  exclusively  occupied  with 
giving  the  anaesthetic  ;  he  should  watch  the  respiration 
and  pulse  throughout  the  whole  time,  and  should  be  a 
qualified  medical  man.  The  drop  method  reduces  the 
dangers  and  should  always  be  used.  The  shape  of  the 
mask  should  be  such  as  to  admit  sufficient  air.  A  fresh 
lining  to  the  mask  should  be  used  for  each  case. 

In  view  of  the  dangers  which  are  inseparable  from 
anaesthetics  as  we  have  seen,  a  great  endeavour  is  made  now- 
adays to  restrict  the  use  of  anaesthetics  as  much  as  possible 
and  to  use  local  anaesthesia  instead.  Infiltration  anaes- 
thesia, introduced  by  Schleich,  has  found  many  adherents 
during  the  last  few  years ;  this  very  useful  method  removes 
all  danger  of  poisoning  by  the  drug,  and  is  much  used  for 
minor  surgical  operations.  The  method  is  applicable  only 
to  certain  cases  and  cannot  be  employed  where  there  is 
inflammation  of  the  structures,  and  there  would  be  some 
danger  in  making  a  puncture  in  the  area  around  infective 
foci.  For  major  operations  and  in  laparotomies,  where  we 
can  seldom  be  quite  sure  beforehand  about  the  ultimate 
extent  of  the  operation,  and  where  the  result  depends 
largely  upon  a  condition  of  complete  relaxation  of  the 
abdominal  wall,  this  method  can  only  exceptionalljT"  be  used. 

For  a  number  of  operations  on  fingers  and  toes,  such  as 
amputation,  the  avulsion  of  an  ingrowing  toenail,  whit- 
lows, and  so  on,  Oberst's  method  of  regional  anaesthesia  is 
simpler  and  safer.  The  finger  is  raised  and  emptied  of  its 
blood,  and  then  tightly  ligatured,  a  quarter  to  half  a 
syringeful  of  a  one  per  cent,  cocaine  solution  is  injected  in 
four  places  below  the  seat  of  the  ligature.  Anaesthesia  is 
complete  in  three  to  ten  minutes.  Here  too  any  possibility 
of  danger  of  cocaine  poisoning  is  almost  entirely  excluded, 
though  such  danger  is  always  present  in  the  simple  sub- 
cutaneous use  of  cocaine,  since  there  is  a  great  difference  in 
the  individual  susceptibility  of  patients  towards  cocaine.  In 

222 


PROPHYLAXIS   IN   SURGEEY 

many  cases  anaesthesia  induced  by  local  cold  is  sufficient, 
and  for  private  practice  we  strongly  recommend  ethyl- 
chloride,  introduced  by  Henning  of  Berlin,  and  sold  in 
tubes  of  a  convenient  size.  Its  action  is  very  quick,  but 
does  not  penetrate  so  deeply  as  does  the  ether  spray  which 
has  been  used  for  years. 

Thus  time  ever  brings  with  it  new  methods  by  which  we 
can  lessen  or  entirely  remove  the  pain  of  operative  pro- 
cedures. We  should  not  narrowly  confine  ourselves  to  one 
method,  but  for  any  given  case  should  select  that  method 
which  brings  in  its  train  the  least  risk  of  poisoning  and 
of  infection.  And  we  are  grateful  for  every  new  method 
designed  to  relieve  pain,  though  we  do  not  always  go  quite 
so  far  as  the  inventor  of  the  method,  who  often  is  blinded 
by  his  enthusiasm.  For  nowhere  so  much  as  in  the  field  of 
medicine  do  we  require  a  calm  unbiassed  judgement. 

The  second  great  danger  in  every  operation  is  infection. 
Here  also  fortunately  we  are  now  in  safer  times  than 
during  the  stormy  period  of  antiseptics  which  menaced  the 
patient's  already  weakened  constitution.  We  have  learnt 
that  there  are  dangers  in  the  immoderate  use  of  antidotes  in 
the  form  of  antiseptics,  and  have  outlived  the  time  of  the 
carbolic  spray  and  strong  solutions  of  corrosive  sublimate. 
We  cannot  do  altogether  without  antiseptics,  especially  for 
wounds  which  are  already  infected,  but  we  should  endeavour 
to  restrict  their  use  more  and  more,  and  most  surgeons 
today  are  of  opinion  that  we  could  altogether  dispense  with 
the  use  of  antiseptics  if  we  could  make  sure  that  there  was 
no  infection  present  before  the  operation.  Under  such 
conditions  asepsis  would  be  justified.  With  our  present 
exact  methods  of  investigation  and  the  advances  made  in 
bacteriological  research,  the  requirements  for  aseptic  opera- 
tions have  enormously  increased,  and  we  are  very  apt 
nowadays  to  lose  ourselves  in  a  minute  attention  to  details 
to  the  exclusion  of  the  wider  aspects  of  the  subject. 
Exact  inquiry  is  esential,  but  if  the  demands  which  it  makes 
continue  to  increase  as  at  present,  from  gloves  to  a  mask 
for  the  face  and  a  bandage  for  the  head,  it  will  be  at  the 
cost   of   the   dexterity  of   the   operator,   and  will   tend  to 

223 


THE  PEEVENTION  OF  DISEASE 

foster  a  certain  over-anxiety  and  pessimism  wliich  in  tlie 
interests  of  the  patient  should  be  avoided. 

Tlie  question  of  wound  infection  and  antiseptics  will  be  ' 
detailed  later,  and  we  need  liere  mention  only  those  pre- 
cautionary measures  which  should  be  generally  followed  in 
every  operation.  The  patient  runs  some  risk  both  from  the 
operator  himself  and  from  his  assistants,  and  it  is  therefore 
essential  that  no  one  should  assist  except  those  whom 
the  operator  can  thoroughly  trust.  The  main  principle 
should  be  to  have  as  few  hands  as  possible  engaged  in  the 
operation  and  in  the  handling  of  the  instruments  used.  We 
have  not  yet  learned  how  to  make  our  hands  perfectly  free 
from  germs,  and  the  surgeon  and  his  assistants,  at  any  rate 
at  major  operations,  should  avoid  touching  any  infectious 
things  or  wounds.  There  are  a  great  number  of  methods 
for  sterilizing  the  hands,  but  for  practical  purposes  Fllr- 
bringer's  method  remains  the  best :  after  previous  thorough 
cleansing  with  soap  and  brush,  alcohol  is  used  to  remove 
any  fat,  and  afterwards  a  solution  of  corrosive  sublimate 
(one  in  a  thousand).  The  hands  should  be  carefully  kej)t,  as 
it  has  been  proved  experimentally  how  much  more  difficult 
it  is  to  disinfect  rough  and  cracked  hands.  It  has  been 
shown  that  it  is  impossible  to  keep  the  hands  sterile  during 
a  long  operation,  and  gloves  were  therefore  introduced,  but 
have  not  yet  been  universally  adopted,  owing  to  certain 
disadvantages.  As  to  instruments,  we  are  now  in  the 
happy  position  to  be  able  to  sterilize  by  steam  instru- 
ments and  ligatures,  when  made  of  silk  or  of  metal,  and 
surgeons  are  therefore  gradually  giving  up  the  use  of  catgut 
ligatures  and  other  materials  which  cannot  be  thus 
sterilized. 

A  further  source  of  danger  in  operations  arises  from  the 
surrounding  air,  which  should  be  free  from  dust  and  so  far 
as  is  possible  free  from  germs.  Good  ventilation  is  there- 
fore essential,  and  infectious  wounds  should  not  be  dressed 
in  the  operating  room  when  this  can  be  avoided.  The 
room  should  be  so  constructed  that  there  are  no  corners, 
and  that  every  part  of  it  can  be  thoroughly  washed  out, 
and  there  should  be  an  adjoining  room  for  sterilizing  and 

224 


PROPHYLAXIS  IN   SURGERY 

bathing.  It  is  absolutely  essential  that  the  patient  should 
have  a  bath  immediately  before  the  operation,  and  that  the 
part  which  is  to  be  operated  upon  and  the  hands  of  the 
operator  should  be  made  sterile,  so  far  as  it  is  in  our 
power. 

We  have  considered  only  those  precautions  which  are  most 
important  on  the  whole ;  but  there  are  numerous  minor 
details  which  every  operator  will  observe  who  claims  that 
he  works  aseptically,  and  these  can  only  be  learned  in 
course  of  time  by  careful  study. 

Whoever  is  not  in  a  position  to  carry  out  all  these  rules, 
as  is  generally  the  case  in  private  practice,  should  follow  all 
the  instructions  laid  down  for  the  antiseptic  treatment. 

After  the  operation  come  the  critical  days  when  the 
pulse,  the  temperature  and  the  general  condition  of  the 
patient  must  be  watched,  and  any  deviation  from  the 
normal  course  at  once  reported,  so  that  suitable  treatment 
may  be  adopted  and  so  that  no  symptom  be  unnoticed  and 
allowed  to  get  worse.  One  should  always  bear  in  mind  the 
rule  that  it  is  better  to  change  a  dressing  too  often  than 
to  expose  the  patient  to  the  risk  of  a  spreading  suppuration 
of  the  wound. 

Esmarch's  bloodless  method,  introduced  for  operations 
upon  the  extremities,  is  an  excellent  method  for  preventing 
the  exhaustion  which  follows  severe  loss  of  blood  during 
operations  ;  indeed  haemorrhage  during  such  operations  may 
be  altogether  avoided  by  this  method.  In  major  operations 
on  the  abdomen  or  trunk  haemorrhage  may  be  severe,  and 
to  prevent  serious  consequences  we  make  use  of  the  simple 
method  of  the  subcutaneous  injection  of  saline  solution,  which 
answers  extremely  well  in  these  cases.  Many  surgeons 
employ  these  injections  as  a  prophylactic  in  all  cases  where 
much  haemorrhage  is  likely  to  occur.  A  similar  result  can 
be  obtained  by  rectal  injections  of  large  quantities  of  fluid. 

Often  too  in  surgery  we  perform  operations  which  may 
be  termed  preventive,  for  instance  operations  for  recurrent 
attacks  of  appendicitis  and  for  reducible  herniae.  The 
indications  for  these  operations  are  not  easy  to  determine, 
and  we  must  carefully  weigh  both  the  probability- and  signifi- 

225  Q 


THE  PREVENTION  OF  DISEASE 

Cance  of  unpleasant  and  serious  symptoms  which  may  arise 
and  also  the  possible  risks  of  the  operation.  A  thorough 
knowledge  of  the  latter  and  the  possibility  of  reducing 
them  to  a  minimum  by  preventive  measures  will  enable  us 
to  proceed  with  an  operation  and  carry  the  case  to  a 
successful  issue  instead  of  avoiding  the  operation  from  a  fear 
of  the  consequences.  In  general,  for  the  cases  just 
mentioned,  the  rule  now  is  to  operate  for  recurrent  appen- 
dicitis in  the  interval  between  the  attacks,  and  not  wait 
till  some  subsequent  attack  causes  perforation  of  the 
appendix  and  a  dangerous  peritonitis  is  set  up. 

The  radical  operation  for  reducible  hernia  is  evidently  a 
preventive  operation.  The  operation  should  be  performed 
as  early  as  possible.  It  can  be  easily  done  during  childhood 
and  the  results  are  more  likely  to  be  permanent  than  when 
the  operation  is  performed  in  adult  life. 

To  return  to  Esmarch's  bloodless  method,  which  is  of 
extreme  importance  so  far  as  the  patient  is  concerned, 
for  the  less  the  haemorrhage  the  sooner  will  the  patient 
recover  from  the  results  of  the  operation.  This  method  has 
advantages  too  from  the  surgeon's  point  of  view,  the 
exposed  surfaces  are  free  from  blood  and  enable  him  to  see 
clearly  what  he  is  doing  and  to  operate  as  safely  and 
calmly  as  on  the  dead  body. 

Whenever  it  is  feasible,  we  recommend  that  the  limb  be 
made  bloodless  by  suspension,  and  that  subsequent  digital 
compression  of  the  large  arteries  of  the  limb  be  employed. 
The  subsequent  haemorrhage  is  then  apt  to  be  much  less 
than  when  compression  has  been  exercised  by  means  of  an 
indiarubber  band.  The  general  oozing  may  at  times  be 
very  troublesome  when  the  tourniquet  is  removed.  These 
cases  are  best  treated  by  general  pressure  upon  the  bleeding 
surfaces  for  some  minutes  rather  than  by  the  application  at 
once  of  numerous  ligatures.  The  pressure  stops  some  of  the 
haemorrhage,  and  any  haemorrhage  persisting  should  as 
far  as  possible  be  stopped  by  torsion  of  the  bleeding  vessels, 
so  that  very  few  ligatures  need  be  applied,  for  the  ligature 
after  all  must  be  regarded  as  a  foreign  body  in  the  wound. 

226 


PROPHYLAXIS  IN  SURGERY 


II.     PREVENTIVE  MEASURES  IN  THE  TREATMENT  OF 
WOUNDS. 

Since  the  human  race  has  existed  man  has  in  his  passage 
from  the  cradle  to  the  grave  always  been  exposed  to  the 
risk  of  injuries  and  wounds,  and  has  been  obliged  to  treat 
them.  Even  skulls  from  prehistoric  graves  have  been 
found  which  show  the  marks  of  trephining.  We  know 
that  thousands  of  years  ago  the  Indians  and  Egyptians 
practised  surgery  with  great  skill,  and  that  today  we 
still  carry  out  their  methods  for  certain  plastic  operations 
upon  the  face.  The  greatest  step  forward  which  surgery 
has  taken  during  the  last  twenty  years  is  closely  related  to 
the  question  of  the  treatment  of  wounds.  After  Lister 
conceived  the  idea  that  all  inflammations,  suppuration  and 
decomposition  attendant  upon  wounds,  were  traceable  to 
the  entrance  of  micro-organisms  into  the  wound,  he  intro- 
duced his  antiseptic  method,  which  in  a  brief  space  of  time 
spread  over  the  entire  civilized  world. 

Although  favourable  results  followed  this  treatment,  such 
as  had  never  before  entered  our  thoughts,  and  opened  up 
new  realms  to  surgery,  yet  certain  disadvantages  appeared 
too  which  everywhere  surgeons  strove  to  remove.  Among 
German  surgeons  who  worked  at  introducing  improve- 
ments in  the  treatment  of  wounds,  and  at  j)ei'fecting  this 
method,  the  names  Von  Bergmann,  Bruns,  Neuber,  Volk- 
mann,  Bardeleben  and  Maass  are  familiar  to  us,  and  the 
antiseptic  period  passed  into  the  aseptic  j)eriod.  We  have 
intentionally  avoided  saying  that  the  one  has  displaced 
the  other,  because  we  are  of  opinion  that  asepsis  does 
not  exclude  antisepsis,  but  that  each  is  a  complement  of 
the  other.  In  his  textbook  of  Antiseptic  Surgery,  when 
treating  of  the  practicability  of  the  aseptic  treatment  of 
wounds,  Watson  Cheyne  writes :  "  The  method  is  theo- 
retically correct,  and  can  be  successfully  carried  out  by 
skilled  bacteriologists,  but  the  risks  of  error  are  so  great 
that  an  ordinary  surgeon,  who  has  not  had  a  prolonged 
bacteriological  training,  meets   with  so   many   difficulties 

227 


THE   PREVENTION   OF  DISEASE 

that   the   results  cannot   compare  with  those  attained  by- 
antisepsis." 

When  we  call  to  mind  the  conditions  which  existed  in 
our  surgical  wards  before  Lister's  time,  we  shall  realize  the 
immense  changes  brought  about  in  a  short  space  of  time 
by  antisejDsis.  In  those  days  it  was  a  rare  exception  to 
find  an  amputation  stump,  or  a  compound  fracture,  heal- 
ing without  inflammation  and  suppuration.  Indeed  even 
slight  unimportant  injuries  were  frequently  attacked  by- 
erysipelas,  hospital  gangrene,  tetanus  or  fatal  septi- 
caemia. Volkmann  has  openly  stated  that  he  was  on  the 
point  of  closing  his  wards  because  he  was  powerless  to  do 
anything  more  against  these  infective  diseases  of  wounds, 
yet  a  few  years  later  he  was  able  to  report  129  amputations 
with  only  one  death  from  wound  infection.  In  Nussbaum's 
surgical  wards  at  Munich,  every  case  of  compound  frac- 
ture ended  fatally,  and  eighty  per  cent,  of  all  cases  of 
wounds  and  ulcers  became  a  prey  to  hospital  gangrene ; 
yet  shortly  afterwards,  without  making  any  other  alter- 
ations except  the  introduction  of  the  antiseptic  method, 
Nussbaum's  results  were  as  brilliant  as  those  obtained  by 
surgeons  at  Halle.  "When  a  method  is  known  to  have 
brought  about  such  enormous  results,  the  reasons  which 
would  induce  us  to  abandon  that  method  must  be  very 
cogent,  or  we  must  be  in  a  position  to  substitute  for  this 
method  a  still  better  one.  As  to  the  former  it  should 
be  remembered  that  the  antiseptic  substances  we  employ 
are  very  different  one  from  another,  and  that  a  slight 
increase  in  the  effect  produced  may  suffice  seriously  to 
injure  the  organism.  Yet  this  slight  excess  can  never 
beforehand  be  definitely  determined,  for  different  people 
show  a  marked  difference  in  their  susceptibility  to  these 
substances,  and  the  amount  which  will  produce  symptoms 
of  jDoisoning  varies  much  with  individuals.  Nevertheless 
our  experience  during  the  last  twenty  years  has  taught  us 
clearly  how  far  we  may  in  general  venture  in  the  use  of 
antiseptics,  and  we  are  able  at  the  present  day  to  use  anti- 
septics of  a  strength  which  only  in  rarest  cases  lead  to  any 
ill  effects.     Practical  experience  in  this  matter  is  the  best 

228 


PROPHYLAXIS   IN   SURGERY 

guide,  while  theory  which  aims  at  removing  one  danger 
only  brings  in  its  train  other  dangers.  To  pursue  this 
course  would  be  to  give  up  the  beneficent  action  of  nar- 
cotics, to  dispense  with  the  good  effects  of  mercury  and  of 
potassium  iodide,  and  lastly  even  to  renounce  the  use  of 
salicylic  acid.  Today  we  use  antiseptics  only  when  we 
cannot  secure  conditions  of  asepsis,  as  often  occurs  in 
private  practice,  or  when  inflammation  or  suppuration 
already  exists,  and  we  cannot  look  upon  antiseptics  as  in- 
jurious when  we  see  the  good  results  obtained  by  their  use. 
We  can  truly  affirm  today  that  we  possess  a  method  by 
which,  with  an  ever  diminishing  number  of  exceptions,  we 
can  prevent  these  infective  diseases  from  attacking  wounds 
and  extensive  injuries,  and  have  removed  what  was  a 
source  of  terror  to  surgeons  in  former  years. 

The  correct  use  of  asepsis  and  antisepsis  is  not  the  only 
measure  we  adopt  in  the  preventive  treatment  of  wounds, 
but  a  number  of  other  points  also  require  attention.  Before 
we  attempt  to  close  a  wound  by  stitches,  all  haemorrhage 
must  be  stopped.  Here  again  the  principle  should  be  to 
employ  the  simplest  method  and  to  stop  haemorrhage  by 
compression,  except  when  the  vessel  is  large  and  would 
be  apt  to  open  again.  The  ligature  in  unfavourable 
conditions  is  a  source  of  some  irritation,  and  may  act  as  a 
foreign  body  and  delay  the  rapid  healing  of  the  wound. 
Sutures  should  be  very  carefully  placed,  especially  when 
we  wish  to  avoid  scars,  as  on  the  face,  and  the  edges  of  the 
wound  must  be  carefully  approximated.  This,  together 
with  a  very  careful  handling  of  the  injured  tissues, 
which  must  not  be  mechanically  or  chemically  injured  by 
strong  antiseptics,  will  prevent  exudation  if  the  wound  is 
recent.  When  exudation  cannot  be  prevented,  as  in  the 
case  of  wounds  impregnated  with  mud  from  the  street,  it  is 
better  not  to  try  to  obtain  primary  union  by  suturing. 
When  the  wound  is  large,  and  there  are  recesses  and 
pockets  in  which  blood  and  exudation  products  may 
accumulate,  these  cavities  must  be  emptied,  and  the  sides 
kept  together  by  stitches,  or  they  must  be  plugged. 
Plugging,    especially,    may   be   regarded    as    a    sovereign 

229 


THE   PRE^rENTION  OF   DISEASE 

remedy  against  the  dangers  of  infection  which  always 
threaten  a  wound  cavity,  as  after  extirpation  of  the  rectum, 
which  cannot  be  kept  perfectly  clean,  and  it  should  also 
be  used  in  recent  wounds  which  for  other  reasons  cannot 
be  safely  disinfected.  Sutures  should  not  be  too  close 
together,  otherwise  the  nutrition  of  the  wound  edges  is 
interfered  with  ;  indeed  even  gangrene  of  the  part  may 
be  caused  by  sutures  which  are  too  tightly  drawn.  A  task 
which  confronts  the  surgeon  as  frequently  as  does  the  treat- 
ment of  recent  wounds,  is  the  treatment  of  wounds  which 
are  already  infected,  so  that  they  may  heal  aseptically. 
When  we  remember  that  in  the  case  of  most  wounds  we 
cannot  know  whether  the  wound  became  infected  at  the 
moment  it  was  inflicted,  the  question  naturally  arises, 
"  How  long  after  the  infliction  of  a  wound  is  it  still 
possible  to  make  the  wound  aseptic,  and  which  methods  are 
of  value  ?  " 

In  the  year  189-4,  Schimmelbusch  gave  an  account  of  his 
recent  experiments  upon  the  infection  of  wounds,  and  the 
result  was  to  influence  us  greatly  in  our  treatment  of 
wounds.  His  inoculations  of  mice  and  guineapigs  with 
cultures  of  anthrax  and  streptococci  jaelded  astonishing 
results,  and  the  great  differences  observed  in  the  reaction 
to  the  virus  shown  by  the  various  animals,  made  him 
feel  that  he  was  not  justified  in  applying  the  conclu- 
sions to  man.  He  mentions  the  difficulty  of  getting  a 
virus  whose  degree  of  virulence  is  constant,  quite  apart 
from  the  consideration  of  the  varying  susceptibility  of 
individual  animals  to  the  virus,  so  that  we  might  almost 
get  the  impression  that  each  animal  had  its  own  special 
exciting  causes  of  suppuration.  Most  remarkable  of  all 
was  the  rapid  absorption  of  bacteria,  which  made  it  impos- 
sible to  disinfect  the  wound  and  save  the  animal,  though 
antiseptics  were  immediately  afterwards  applied  to  the 
wound  which  had  been  infected  with  anthrax  or  strepto- 
cocci. Fortunately  this  rapid  absorption  and  virulence  of 
the  bacteria  occurs  only  in  recent  bleeding  wounds,  and 
then  only  when  the  poison  has  been  inserted  in  the  recesses 
of  the  wound. 

230 


PROPHYLAXIS   IN   SURGERY 

Further  tlie  risk  of  infection  of  recent  wounds  diminishes 
from  day  to  day  as  the  wound  gets  older  ;  and  wounds 
which  are  from  twenty-four  to  forty-eight  hours  old  are 
very  resistant  to  bacteria,  and  can  only  seldom  and  with 
difficulty  be  infected.  These  results  were  later  confirmed 
by  a  number  of  investigators,  who  mostly  worked  with 
very  virulent  cultures,  till  Henle's  researches  made  with 
less  virulent  pus  cocci,  showed  that  it  was  possible  to 
sterilize  wounds  with  a  corrosive  sublimate  solution  of  a 
strength  of  one  in  a  thousand,  three  hours,  and  in  some 
cases  even  eight  hours,  after  they  had  been  infected.  Mess- 
ner's  experiments  showed  that  with  one  single  exception, 
gangrene  or  fatal  sepsis  supervened  when  the  infected 
wounds  were  treated  aseptically,  while  in  all  cases  which 
were  treated  antiseptically  the  infection  remained  localized. 
We  see  then  how  widely  individual  results  differ  even  with 
the  most  careful  and  exact  investigators,  and  must  there- 
fore avoid  drawing  definite  conclusions  from  these  results. 
Nevertheless  all  authorities  agree  that  the  main  principles 
of  asepsis  as  carried  out  today  in  the  treatment  of  infected 
and  noninfected  wounds  in  general  are  correct. 

The  after  treatment  and  a  watchful  care  of  the  patient 
are  part  of  the  surgeon's  work.  Rest  is  one  of  the  most 
important  conditions  for  the  healing  of  a  wound.  For  a 
wound  on  the  lower  extremities  it  is  therefore  advisable 
that  the  patient  should  be  kept  lying  down  ;  in  this  way 
we  secure  for  the  injured  limb  the  most  favourable  condi- 
tions for  a  good  circulation,  and  this  plays  an  important 
part  in  the  healing  of  wounds.  For  wounds  of  the  upper 
extremities  we  should  prevent  obstruction  to  the  circula- 
tion and  the  accumulation  of  exudations  by  placing  the 
patient  in  a  suitable  posture,  keeping  the  limb  raised,  and 
thus  aiding  the  return  of  the  venous  blood.  According  to 
our  present  views,  the  dressing  should  be  kept  dry,  and  it 
is  therefore  necessary  to  change  the  dressing  when  it  is 
seen  to  be  soaked  through  with  blood  and  exudation.  The 
dressing  must  also  be  changed  if  it  becomes  at  all  displaced, 
or  if  there  is  pain,  because  an  uncomplicated  wound  if 
properly  treated  ought  to  give  rise  to  no  pain.     Obviously 

231 


THE  PREVENTION  OF  DISEASE 

too  tlie  dressing  must  be  changed  immediately  if  there  is 
any  disturbance  in  the  general  condition  of  the  patient  or 
any  rise  of  temperature.  If  all  these  precautions  have  been 
carefully  observed,  we  can  then  with  a  good  conscience 
view  any  disturbance  which  may  arise  in  the  healing 
process,  though  such  disturbance  is  fortunately  most  rare 
nowadays,  and  we  shall  still  be  in  the  position  to  take 
adequate  measures  to  prevent  greater  mischief  and  those 
devastating  infectious  diseases  of  earlier  times. 

Buchner  has  called  attention  to  one  matter  in  which  we 
still  fail :  we  do  not  avail  ourselves  sufficiently  of  nature's 
means  of  defence  provided  against  infective  processes.  The 
blood  is  the  most  important  of  these,  owing  to  its  absorptive 
and  bactericidal  properties.  To  further  absorption  and  the 
healing  process,  'a  large  quantity  of  blood  is  required  by 
the  injured  part,  and  a  stronger  local  circulation,  so  that 
the  tissues  may  be  bathed  with  more  blood  in  a  given  time 
than  is  usual.  How  this  may  practically  be  accomplished 
will  be  described  later. 

The  rules  laid  down  for  the  correct  treatment  of  wounds 
were  drawn  up  in  accordance  with  results  obtained  in  the 
treatment  of  compound  fractures.  In  his  well  known  work 
on  the  treatment  of  compound  fractures,  which  prepared 
the  way  for  the  antiseptic  treatment  of  wounds,  Volkmann 
taught  that  in  a  compound  fracture,  with  the  exception 
of  fractures  caused  by  puncture,  the  wound  should  be 
thoroughly  laid  open  and  all  recesses  be  followed  up ;  in 
brief,  he  advocated  the  so-called  "incision  method"  of  treat- 
ing compound  fractures.  The  method  was  adopted  by 
most  STirgeons  and  practised  without  modifications  till 
the  results  obtained  by  Von  Bergmann  in  the  Eusso- 
Turkish  war  were  made  known.  In  the  severe  injuries 
treated  during  this  war  Von  Bergmann  avoided  wherever 
possible  making  any  examination  of  the  wound  :  he  simply 
dressed  the  wound  and  at  once  put  the  limb  in  a  plaster 
of  Paris  bandage.  The  results  were  brilliant.  They 
tended  to  introduce  a  more  expectant  method  of  treatment 
for  compound  fractures  met  with  in  civil  life.  And  then 
our  highly  esteemed  teacher,  Maass,  taught  as  the  result 

232 


PROPHYLAXIS   IN   SURGERY 

of  experience  gained  from  injuries  inflicted  in  various 
severe  railway  accidents,  that  equally  good  results  could 
be  obtained  in  the  treatment  of  compound  fractures  when 
incisions  were  not  used,  and  the  surface  around  the  wound 
was  thoroughly  disinfected  and  the  wound  was  merely 
dressed  antiseptically  and  only  touched  so  far  as  was 
necessary  to  remove  loose  pieces  of  bone  and  tissue, 
Maass  started  with  the  correct  assumption  that  the  excit- 
ing causes  of  these  infective  diseases  of  wounds  were  not 
present  everywhere.  There  are  indeed  micro-organisms  in 
the  mud  which  may  get  into  the  wound,  but  these  micro- 
organisms are  not  pathogenic.  And  as  early  as  the  year 
1885  Maass  was  able  to  describe  forty-five  cases  of  com- 
pound fracture  with  only  three  deaths,  and  in  these  three 
cases  death  was  not  in  any  way  connected  with  the  treat- 
ment of  the  wound.  All  other  cases  treated  by  this  con- 
servative method  healed  without  any  of  them  becoming 
affected  by  a  wound  infection.  Similar  good  results  were 
recorded  in  other  hospitals,  and  thus  the  conservative 
method  was  introduced.  Not  only  compound  fractures  but 
all  other  wounds  should  so  far  as  is  possible  be  treated  con- 
servatively. This  is  especially  true  of  gunshot  injuries, 
where  prophylactic  measures  in  examining  the  wound  are  of 
the  utmost  importance.  Examination  with  finger  or  probe 
should  be  performed  as  little  as  possible,  and  every  opera- 
tive procedure  is  wrong,  even  though  the  bullet  may  be 
felt  directly  below  the  skin,  and  under  no  circumstances 
should  we  disturb  this  subcutaneous  lesion. 

When  the  soft  parts  are  extensively  injured  and  the 
wound  possibly  dirty  there  is  still  no  direct  reason  for 
operating  in  all  cases.  If  the  wound  is  so  situated  that 
the  exudation  can  easily  flow  out,  simple  irrigation  is 
sufficient,  with  antiseptic  dressing  of  the  wound  and  fixa- 
tion of  the  limb.  Operation  should  only  be  resorted  to 
when  it  is  feared  that  the  bone  or  soft  parts  will  cause 
retention  of  secretion  or  the  patient  becomes  feverish. 


233 


THE   PREVENTION  OF   DISEASE 

III.    PROPHYLAXIS  IN  THE  TREATMENT  OF  INFLAM- 
MATORY PROCESSES. 

Pain  is  one  of  tlie  cardinal  symptoms  of  inflammation, 
and  is  the  symptom  which  makes  the  patient  most  uneasy 
and  induces  him  to  seek  for  medical  aid.  We  have  already?- 
stated  elsewhere  that  the  endeavour  to  relieve  pain  is  one 
of  the  noblest  aims  of  the  physician,  and  we  state  it  again 
here  because  the  cessation  of  pain  in  inflammatory  pro- 
cesses is  in  general  an  indication  that  the  process  is  at  a 
standstill  or  is  retrogressing.  To  effect  this,  the  essential 
requirement  at  the  commencement  of  every  inflammatory 
process  is  rest.  By  the  term  "  rest "  we  mean  medically 
much  more  than  is  denoted  by  it  in  ordinary  life,  and  it 
includes  a  number  of  means  all  designed  to  procure  those 
conditions  which  are  required  for  the  cure  of  the  diseased 
part.  First  among  these  is  a  suitable  posture.  The  great- 
est pleasure  for  the  physician  when  called  for  the  first 
time  to  a  patient  who  is  suffering  much,  is  to  be  able  at 
once  and  possibly  bj^  some  simple  device  to  rid  him  of  his 
pain  or  at  least  to  alleviate  it.  In  this  respect  doctors 
often  err  greatly,  especially  in  treating  surgical  cases. 
Students  hear  mostly  very  little  about  this  matter,  and  yet 
it  is  important  they  should  know  that  the  affected  knee 
can  be  most  efficiently  put  at  rest  by  placing  it  so  that  it 
is  slightly  flexed,  with  a  support  behind  the  knee  which 
does  not  press  upon  the  vessels  of  the  popliteal  space  ;  and 
that  the  most  comfortable  position  for  the  hip  joint  is, 
according  to  the  degree  of  the  local  disease,  either  slight 
flexion  or  abduction  or  a  combination  of  these  two.  If  the 
limb  itself  is  affected  it  should  be  so  placed  that  the 
circulation  is  unimpeded  ;  to  prevent  venous  obstruction 
the  distal  end  should  be  at  a  higher  level  than  the  proxi- 
mal, and  it  may  be  necessary  to  assist  the  venous  circu- 
lation still  further  by  bandaging  the  whole  limb.  These 
mechanical  aids  are  far  more  efficacious  than  the  icebag 
and  compress,  whose  chief  value  consists  in  their  subjective 
influence  upon  the  patient.  It  is  necessary  to  individualize 
for  special  cases.    Thus,  for  the  head,  when  there  is  anaemia, 

234 


PROPHYLAXIS   IN   SURGERY 

of  tlie  brain,  general!}^  indicated  by  great  pallor  of  tbe  face, 
we  should  select  the  horizontal  position  for  the  body  and 
head,  or  even  let  the  head  be  slightly  lower  than  the  body  ; 
while  if  the  vessels  of  the  brain  and  membranes  are  con- 
gested and  the  colour  of  the  face  is  bluish,  we  should  see 
that  the  head  and  upper  part  of  the  body  are  maintained 
upright.  Unless  these  points  are  observed  icebags  and 
other  medical  applications  will  be  of  no  avail.  These  are 
the  main  principles  upon  which  all  further  measures  to 
remove  inflammation  and  prevent  its  spread  must  be  based. 
In  general  we  may  say  that  it  is  possible  to  remove  inflam- 
mation in  the  majority  of  cases  when  it  has  not  passed 
beyond  the  first  stage,  but  often  unfortunately  we  do  not 
see  these  inflammator}^  processes  till  there  is  some  amount 
of  infiltration  or  deep  suppuration. 

Before  all  else  it  is  then  essential  to  prevent  a  spread  of 
the  inflammation  and  to  utilize  all  the  resources  available 
in  the  organism.  The  diseased  area  is,  as  we  know,  to  a 
certain  extent  cut  off  from  the  general  circulation  of  the 
body  by  a  bulwark  in  the  form  of  thrombi  and  by  the 
reaction  of  the  surrounding  healthy  structures.  This  pro- 
tecting wall  gives  way  the  moment  the  pressure  within 
the  affected  area  becomes  too  great,  the  boundary  line  is 
passed  and  the  body  must  again  work  at  forming  a  fresh 
protective  bulwark.  But  with  the  giving  way  of  the 
boundary  wall  there  is  the  possibility  of  a  general  infec- 
tion with  its  often  fatal  consequences,  and  this  we  must 
endeavour  to  prevent  in  every  possible  way.  This  is  best 
done  by  incisions,  which  relieve  the  tension  and  at  the 
same  time  provide  a  way  of  escape  for  the  accumulating 
pathological  secretions.  It  is  evident,  as  previously  stated, 
that  our  methods  of  treatment  must  be  based  upon  phj^si- 
cal  laws  and  be  aided  by  the  powers  given  by  nature  if  we 
are  to  combat  successfully  the  many  injurious  influences 
brought  to  bear  upon  the  body. 

Free  incisions  are  needed  for  well  marked  suppurative 
inflammation,  but  in  making  them  it  must  be  remembered 
that  we  wish  also  ultimately  to  restore  the  functions  of 
the  diseased  part.     The  incisions  should  therefore  always 

235 


THE   PREVENTION   OF  DISEASE 

be  made  in  the  longitudinal  axis  of  the  trunk  or  limb ; 
they  should  be  parallel  to  one  another  and  placed  so  as  to 
avoid  vessels  and  nerves.  In  this  way  we  obtain  smooth 
and  non-adherent  scars  and  we  shall  not  interfere  with  the 
functions  of  the  limb.  "When,  as  often  happens  in  the 
country,  cases  are  brought  for  treatment  only  after  the 
process  has  advanced  far,  with  extensive  loss  of  skin,  we 
should  as  soon  as  the  wound  is  clean  cover  the  exposed 
surface  by  Thiersch  grafts  or  by  grafting  with  pieces  of 
skin,  either  stalked  or  unstalked,  and  thus  prevent  contrac- 
tions which  would  interfere  with  the  free  use  of  the  limb. 

Incisions  alone  are  not  enough  ;  a  free  outlet  for  the 
pus  must  also  be  provided,  and  the  means  to  be  adopted 
have  already  been  mentioned,  namely,  plugging,  drainage, 
and  irrigation  with  weak  antiseptic  solutions. 

One  other  point  requires  mention.  When  the  products 
of  inflammation  are  within  a  rigid  walled  cavity,  an 
operation  should  be  undertaken.  For  empyema  of  the 
frontal  sinus  we  trephine  the  frontal  bone  ;  for  empyema 
of  the  pleura  we  resect  one  or  more  ribs ;  for  acute  infec- 
tive osteo-myelitis  we  chisel  open  the  long  bone  in  its 
entire  length  in  order  that  the  diseased  marrow  may 
escape.  All  this  is  prophylactic  treatment,  and  by  these 
timely  operations  we  save  the  patient  from  chronic  disease 
or  even  from  death. 

By  carrying  out  this  treatment  from  the  commence- 
ment we  are  nowadays  in  the  happy  position  of  being 
able  in  a  very  large  majority  of  cases  to  prevent  a  process 
which  is  still  local  from  spreading  and  setting  up  a  general 
infection.  The  case  is  otherwise  with  specific  inflamma- 
tions, but  these  cannot  here  be  described  as  our  object  is 
to  give  a  sketch  of  preventive  treatment  from  the  general 
standpoint,  for  every  method  of  treatment  is  in  a  sense 
prophylactic.  For  instance,  in  commencing  tuberculosis  of 
a  joint,  we  endeavour  to  put  the  joint  at  rest,  to  remove  all 
strain  upon  it,  and  by  extension  to  keep  the  two  articular 
surfaces  from  touching  one  another ;  our  object  is  to  pre- 
vent destruction  of  the  joint,  to  cure  it  quickly,  and  to 
restore  its  function. 

236 


PROPHYLAXIS  IN  SURGERY 

Thanks  to  this  conservative  tendency  in  surgery,  excisions 
in  early  childhood,  which  so  much  crippled  the  joint,  have 
almost  ceased  to  be  performed.  This  conservative  method 
should  always  be  kept  in  mind  and  all  operations  avoided 
which  would  impair  the  function  of  the  part.  Therefore  we 
welcome  Bier's  "  stasis  method  "  for  tuberculous  joints  as  a 
great  step  forward,  and  we  make  use  of  nature  by  venous 
hypersemia  to  carry  on  the  struggle  against  the  invaders 
with  success.  And  the  results  of  the  hot  air  treatment  of 
chronic  inflammations  of  joints  seem  to  be  brought  about  by 
arterial  hyperaemia,  which  enables  absorption  and  regenera- 
tion by  the  blood  to  go  on  more  vigorously  and  for  a  longer 
time.  This  is  in  close  accord  with  the  views  of  Buchner, 
who  considers  that  practical  methods  in  the  future  will 
rely  more  and  more  upon  effects  produced  through  the 
circulation. 

B.    Special    Prophylaxis 

I.  PROPHYLAXIS  IN  THE  TREATMENT  OF  FRACTURES 

Prophylactic  treatment  in  the  strict  sense  of  the  word 
is  not  applicable  to  fractures  and  dislocations,  but  in  speak- 
ing about  the  general  etiology  of  fractures  we  shall  find 
that  the  mode  of  life  and  occupation  exercise  an  important 
influence  upon  individual  predisposition  to  fractures  and 
expose  certain  individuals  more  or  less  to  the  danger  of 
sustaining  fractures.  Moreover  we  consider  that  the 
principles  and  rules  which  should  be  our  guide  in  the 
treatment  of  fractures  and  dislocations,  especially  when 
dressing  them  for  the  first  time,  belong  to  prophylaxis. 

Above  all  we  should  aim  from  the  very  first  at  restoring 
the  part  to  its  normal  function,  and  this  will  only  be  pos- 
sible if  we  have  a  due  appreciation  of  the  errors  which  may 
be  made  in  treating  fractures.  It  matters  very  much 
whether  the  treatment  of  a  simple  fracture  of  the  malle- 
olus leaves  the  patient  after  a  short  time  with  a  movable 
ankle  and  able  to  walk  as  well  as  he  could  before  the 
fracture,  or  whether  it  leaves  him  a  cripple  for  life  with  a 
foot  fixed  in  the  valgus  position.     We -need  scarcely  point 

237 


THE  PREVENTION  OF  DISEASE 

out  that  this  is  not  a  rare  occurrence  after  a  simple 
fracture.  Every  experienced  surgeon  has  had  many  such 
cases  brought  to  his  notice  where  the  bad  result  could  only 
be  ascribed  to  bad  treatment.  In  no  other  cases  is  it  so 
all-important  that  the  first  splints  or  bandages  should  in 
every  way  be  very  exactly  applied  if  we  are  not  afterwards 
to  see  patients  walking  about  crippled  who  might  with 
better  treatment  have  been  completely  restored.  When  a 
fracture  near  a  joint  has  united  in  bad  position,  it  is 
generally  impossible  to  put  things  right  even  by  a  further 
operation.  Nowadays  too,  thanks  to  laws  about  acci- 
dents, no  workman  would  care  to  undergo  an  operation 
which  promised  to  improve  his  condition  and  would  at  the 
same  time  reduce  his  allowance.  It  would  seem  too  that 
the  laws  against  doctors  for  mal  praxis  are  to  be  more 
stringent,  and  for  this  reason  greater  caution  should  be 
exercised.  In  the  following  paragraphs  we  shall  consider 
more  in  detail  the  etiology  of  fractures  and  dislocations 
and  of  predisposing  causes,  some  of  which  depend  upon 
external  conditions,  others  upon  the  condition  and  nature 
of  the  bone,  and  thus  we  shall  learn  what  are  the  mistakes 
which  may  lead  to  bad  results. 

Among  the  various  kinds  of  injury  caused  by  accidents 
and  requiring  surgical  treatment,  fractures  are  the  most 
common.  Statistics  from  the  Reports  of  the  London 
Hospital,  extending  over  a  period  of  a  few  years,  showed 
that  among  307,352  injuries  reported,  45,781  were  fractures, 
that  is  a  percentage  of  14-9,  so  that  fractures  constituted  a 
seventh  part  of  all  accidents  treated  there. 

Age  has  an  important  influence  upon  fractures.  In 
childhood  fractures  of  the  bones  of  the  forearm  are  the 
most  common ;  next  come  fractures  of  the  humerus, 
especially  of  its  lower  articular  end,  and  fractures  of  the 
clavicle.  In  adult  life  fractures  of  the  upper  limb  are  less 
common  than  fractures  of  the  lower  limb ;  fractures  of  the 
ribs,  almost  unknown  in  childhood,  are  comparatively 
common  in  adult  life  ;  and  fractures  of  the  patella  and 
olecranon  are  most  common  during  adult  life,  though  very 
rare  in  childhood.     Finally,  in  old  age,  fractures  of   the 

238 


PROPHYLAXIS  IN   SURGERY 

lower  limb  are  the  most  common,  especially  fracture  of  the 
neck  of  the  femur.  Fractures  of  the  radius,  ribs  and  upper 
extremity  of  the  humerus  are  also  common  in  old  age.  For 
diagnostic  purposes,  the  differences  in  the  various  periods  of 
life  are  important,  especially  when  the  signs  of  the  fracture 
are  not  very  evident.  As  an  example,  consider  the  case  of 
a  person  advanced  in  years,  who  falls  and  complains  of 
severe  pain  in  the  region  of  the  hip  joint.  The  signs  of 
fracture  may  not  be  evident,  yet  we  may  with  tolerable 
certainty  assume  that  it  is  a  case  of  fracture  of  the  neck 
of  the  femur,  and  it  will  always  be  best  to  act  upon  this 
assumption  rather  than  have  this  fact  forced  upon  us  later 
to  our  surprise.  Nevertheless,  fractures  of  the  neck  of  the 
femur  in  youth  are  not  quite  so  rare  as  is  generally  thought 
to  be  the  case.  It  would  seem  that  often  they  have  not  been 
diagnosed,  and  the  result  is  most  serious  for  the  patient. 

There  are  great  differences  in  the  degree  of  brittleness  of 
the  various  bones  of  the  skeleton,  and  the  bones  of  some 
individuals  are  much  more  apt  to  fracture  than  the  bones 
of  others.  The  firmness  of  the  osseous  structure  varies  extra- 
ordinarily in  different  individuals  as  well  as  in  the  various 
bones  of  the  same  individual,  and  even  at  different  parts  of 
one  and  the  same  bone.  In  general  we  can  distinguish 
between  predisposing  causes  and  accidental  causes  of  frac- 
tures, and  the  former  are  especially  interesting  to  us  in  so 
far  as  we  are  able  to  take  precautionary  measures  against 
them.  Apart  from  the  physiological  condition  of  the  bone 
itself,  evidenced  by  its  degree  of  firmness  and  elasticity  or 
dependent  upon  the  position  and  function  of  that  particular 
bone,  a  great  factor  in  the  causation  of  fractures  is  to  be 
found  in  the  individual's  mode  of  life  and  occupation  ;  and 
certain  fractures  have  therefore  been  termed  "  workmen's 
fractures."  The  season  of  the  year  also  has  some  influence, 
especially  in  large  towns,  where  workpeople  have  to  go 
long  distances  to  their  work ;  and  there  is  a  marked 
increase  in  the  number  of  fractures  when  the  roads  are 
bad  and  covered  with  snow  and  ice.  Certain  pathological 
conditions  of  the  bone  itself  will  also  predispose  to  fracture. 

The  statistics  mentioned  above  have  shown  us  that  the 

239 


THE   PREVENTION  OF  DISEASE 

greatest  number  of  fractures,  about  43-8  per  cent,  of  all 
fractures,  occur  during  the  middle  period  of  adult  life — 
between  the  ages  of  30  and  60.  This  is  explained  by  the 
fact  that  people  at  this  age  are  most  exposed  to  those 
accidental  causes  of  fractures  met  with  in  workshops, 
factories,  in  building,  and  in  agriculture.  This  will  be 
more  fully  dealt  with  in  the  chapter  on  prophylaxis  against 
accidents,  and  we  now  pass  on  to  consider  pathological  pre- 
disposition to  fractures.  To  this  group  belong  all  those 
diseases  of  bone  which  produce  an  abnormal  brittleness  of 
the  osseous  substance,  so  that  a  very  slight  force,  indeed 
the  mere  contraction  of  a  muscle,  sufEces  to  fracture  the 
bone.  The  practical  importance  of  knowing  this  etiological 
factor  is  evident,  because  often  attention  is  first  drawn  to 
the  existence  of  disease  of  the  bone  by  the  occurrence  of  a 
fracture  without  adequate  external  cause. 

Great  interest  is  attached  to  the  brittleness  of  bones 
produced  by  osseous  atrophy,  and  mostly  seen  in  old  people, 
and  we  cannot  explain  the  frequent  occurrence  of  fractures 
in  very  old  people  otherwise  than  through  the  excessive 
brittleness  of  their  bones.  It  is  therefore  our  duty  to  draw 
the  attention  of  the  relatives  of  aged  people  to  this  danger. 
It  once  happened  to  us  when  performing  artificial  respira- 
tion on  an  old  man  of  seventy  to  hear  a  rib  snap  with 
a  loud  crack,  though  no  great  force  was  being  used. 
When  a  bone  has  not  been  used  for  a  long  time,  in  con- 
sequence of  some  chronic  inflammation  of  a  bone  or  joint, 
or  from  paralysis,  by  which  the  limb  has  been  rendered 
more  or  less  completely  useless  for  years,  great  caution 
must  be  exercised  when  the  patient  gets  about  again,  since 
the  slightest  external  cause,  even  a  clumsy  movement,  may 
suffice  to  fracture  the  bone.  Such  patients  must  very 
slowly  and  gradually  accustom  their  bones  again  to  bear 
the  weight  of  the  body.  Atrophy  of  bone  with  excessive 
brittleness  after  long  disuse  is  not  at  all  uncommon  in 
youth.  Bruns  relates  that  in  a  case  of  hip  disease,  which 
was  cured  after  several  years,  the  femur  broke  in  the  lower 
third  when  a  careful  attempt  was  made  at  passive  move- 
ment of  the  hip  joint. 

240 


PROPHYLAXIS   IN  SURGERY 

There  are,  too,  several  diseases  of  the  central  nervous 
system,  chronic  diseases  of  the  spinal  cord  and  of  the  brain, 
in  which  the  bones  become  very  brittle.  This  condition  of 
the  bones  should  be  constantly  borne  in  mind,  that  the 
patients  may  be  guarded  or  at  least  warned  against  these 
possible  dangers  which  threaten  them.  In  tabes  dorsalis 
Charcot  found  the  primary  cause  of  fracture  to  be  a  nutri- 
tional disturbance  of  the  osseous  tissue  ;  but  spontaneous 
fractures  occur  even  more  frequently  in  general  paralysis. 
It  is  well  known  that  spontaneous  fractures  are  not  at  all 
uncommon  in  lunatic  asylums,  and  when  shortly  after 
death  an  autopsy  is  made  on  the  body  of  such  patients, 
we  find  an  abnormal  degree  of  softness  of  the  bones, 
and  they  have  a  thin  layer  of  compact  osseous  tissue 
and  dark  coloured  marrow,  while  the  cancellous  tissue 
consists  of  a  few  wide  meshes  filled  with  thick  fluid  blood. 
In  most  of  the  cases,  unfortunately  the  external  exciting 
cause  of  the  fracture  is  so  slight  that  it  is  scarcely  possible 
to  guard  patients  against  it.  The  case  is  very  different 
when  the  brittleness  of  the  bone  is  a  consequence  of  osteo- 
myelitis with  necrosis  of  bone.  Here  it  is  always  possible 
to  determine  what  cavities  exist  by  careful  examination 
and  by  a  probe,  or  even  by  the  Rontgen  rays,  and  we  can 
thus  determine  how  much  bone  remains,  and  provide  the 
patient  with  an  apparatus  for  supporting  the  bone  if  there 
is  any  danger  of  possible  fracture. 

In  childhood  the  commonest  predisposing  cause  of  green- 
stick  and  complete  fractures  is  rickets,  and  this  explains 
the  great  frequency  of  fracture  at  this  age.  Greenstick 
fractures  are  particularly  common,  more  common  than  is 
generally  believed,  and  many  such  fractures  are  overlooked. 
This  fact  is  not  surprising  when  we  remember  the  nature 
of  the  rickety  process,  the  abnormal  growth  of  intermediary 
cartilage  and  of  periosteum,  and  the  formation  of  imper- 
fectly calcified  soft  osseous  tissue  instead  of  the  normal  bony 
structure.  All  of  these  conditions  are  particularly  favour- 
able to  the  occurrence  of  greenstick  fracture,  in  which  only 
one  side  of  the  bone  is  fractured,  while  the  other  side  of  the 
bone  is  bent.    The  slightest  external  violence  is  often  enough 

241  E 


THE   PREVENTION  OE   DISEASE 

to  cause  a  greenstick  fracture,  and  a  careless  dragging  by  the 
arm  or  a  fall  on  level  ground  may  fracture  the  bone.  There- 
fore this  angular  bending  occurs  generally  at  typical  places 
and  in  typical  directions  for  the  different  bones.  In  the  leg 
it  is  generally  in  the  lower  third,  and  the  curve  of  the  angle 
is  directed  outwards,  or  more  rarely  forwards  or  inwards ;  in 
the  thigh  it  is  outwards  ;  in  the  forearm,  outwards  ;  in  the 
upper  arm,  inwards.  From  the  nature  of  the  case  it  follows 
that  these  fractures  are  long  in  uniting  in  consequence  of 
the  defective  formation  of  callus,  and  we  should  remember 
that  the  union  of  the  fractured  ends  may  be  hastened  by 
treating  the  rickets.  When  speaking  later  about  deformi- 
ties we  shall  have  an  opportunity  of  mentioning  the  pro- 
phylactic measures  needed  for  the  treatment  of  rickets,  and 
will  merely  state  here  that  the  early  treatment  and  preven- 
tion of  rickets  is  the  best  prophylaxis  against  these  frac- 
tures. It  is  of  importance  to  diagnose  these  greenstick 
fractures  correctly,  that  we  may  correct  the  displacement 
at  once.  Indeed  it  is  often  possible  at  the  same  time  to 
remove  the  rachitic  curvature  if  the  fracture  is  situated 
near  the  curve  or  even  at  the  curve  itself. 

Among  constitutional  diseases  syphilis  was  formerly 
thought  to  be  a  frequent  cause  of  spontaneous  fracture,  but 
nowadays  it  is  thought  that  spontaneous  fracture  as  the 
result  of  syphilis  is  very  rare,  when  the  extraordinary 
frequency  of  syphilis  is  borne  in  mind.  The  many  cases  of 
fracture  occurring  with  syphilis  in  remoter  times  are  prob- 
ably referable  to  local  gummatous  affections  of  bones,  which 
led  to  spontaneous  fracture  when  the  bony  structure  was 
extensively  involved.  On  the  other  hand,  there  is  more 
reason  for  regarding  congenital  syphilis  as  the  primary 
cause  of  fractures  which  occur  before  birth,  during  birth, 
or  soon  after  birth.  In  addition  to  the  local  treatment  of 
the  fracture  itself,  anti-syphilitic  remedies  are  here  of  great 
importance. 

To  complete  this  subject  it  is  necessary  to  mention  that  a 
certain  brittleness  of  the  bones  is  a  consequence  of  scurvy, 
and  that  a  number  of  cases  have  been  published  of  spon- 
taneous fracture  occurring  in  carcinoma  and  in  sarcoma  of 

242 


PROPHYLAXIS   IN   SURGERY 

bone.  Here,  as  well  as  in  cases  of  cysts  and  enchondromata 
of  bones,  it  is  essential  to  make  an  early  diagnosis,  that  tbe 
operative  procednres,  wliicli  are  required  in  some  cases,  may 
be  crowned  with,  success.  The  Eontgen  ray  illumination 
is  a  valuable  aid  in  the  diagnosis  of  affections  of  bones,  and 
it  would  seem  that  early  diagnosis  and  operation  enable  our 
treatment  to  be  more  conservative  than  formerly  it  was, 
and  cases  of  sarcoma  of  bone  for  which  resection  has  been 
performed  instead  of  an  amputation  and  without  recurrence 
have  been  much  more  numerous  of  late  years.  Especially 
is  this  so  when  compared  with  former  years,  when  in  every 
case  of  sarcoma  of  bone  the  affected  limb  was  simply 
amputated. 

There  is  still  another  form  of  brittleness  of  bone,  the 
anatomical  cause  of  which  is  still  obscure,  and  which  is 
therefore  termed  idiopathic.  Here  there  exists  a  strong 
predisposition  to  fracture  without  any  apparent  cause,  and 
in  some  cases  the  only  aetiological  factor  is  heredity,  which 
may  be  traced  through  several  generations.  When  this 
hereditary  predisposition  is  known  to  exist,  the  attention 
of  the  members  of  that  family  should  be  drawn  to-  the 
danger.  No  other  prophylactic  measure  is  practicable,  as 
the  nature  of  the  nutritional  disturbance  in  the  osseous 
structures,  which  is  probably  the  cause  of  the  fracture,  is 
wholly  unknown. 

We  have  separated  the  predisposing  causes  from  the 
accidental  cause,  and  now  will  briefly  consider  the  latter. 

All  possible  kinds  of  force  may  produce  a  fracture  when- 
ever the  force  applied  is  sufficient  to  overcome  the  elasticity 
and  firmness  of  the  osseous  structure.  One  of  the  most 
frequent  causes  is  a  fall  on  the  level  ground  or  from,  a 
height,  or  it  may  be  a  push,  a  blow,  or  being  run  over  by  a 
vehicle,  so  that  in  the  daily  events  of  life  there  are  always 
risks  of  meeting  with  an  accident  which  will  cause  a  frac- 
ture. There  are  a  number  of  occupations,  such  as  slating 
roofs,  which  are  specially  dangerous,  and  these  will  be 
spoken  of  later.  We  cannot  guard  men  against  the 
accidental  causes  which  are  incident  to  daily  life. 

A  few  important  points  will  next  be  considered  in  con- 

243 


THE   PREVENTION  OF  DISEASE 

nexion  witli  the  making  of  the  diagnosis  and  the  first 
application  of  the  splints,  for  upon  these  the  successful 
union  of  the  fracture  and  restoration  of  the  function  of  the 
limb  will  depend. 

The  examination  of  the  injured  person  who  is  suspected 
of  having  sustained  a  fracture  must  first  be  most  thorough, 
for  such  an  examination  only  will  enable  us  to  judge  of  the 
prognosis  and  to  decide  upon  the  treatment  which  is 
required.  And  here  the  old  rule  cannot  be  too  strongly- 
emphasized — first  the  history  of  the  case  should  be  obtained, 
then  an  inspection  be  made,  and  lastly  we  proceed  to 
manual  examination.  The  importance  of  the  exact  history 
of  the  case  is  self  evident  after  what  has  been  said  above 
about  predisposing  causes  of  fractures,  and  it  will  often  give 
us  valuable  information.  It  will  tell  us  how  the  fracture 
was  caused,  whether  by  mere  muscular  action  or  by  direct  or 
indirect  external  violence  ;  and  we  can  find  out  exactly  the 
kind  and  degree  of  the  external  violence  and  the  direction 
in  which  this  force  acted.  In  inspection  the  chief  rule  is  to 
compare  the  two  sides  of  the  body  that  we  may  obtain  a 
correct  estimate  of  the  deformity  present.  Before  inspect- 
ing the  legs  we  must  see  that  so  far  as  possible  the  two 
are  in  exactly  similar  positions,  and  must  note  the  position 
of  the  pelvis ;  and  in  the  case  of  the  upper  limbs  the  two 
shoulders  should  be  at  the  same  level.  We  cannot  go  into 
every  detail,  there  are  so  many  deviations  from  the  normal ; 
for  instance,  increased  or  decreased  length  of  limb,  abnormal 
curvature,  rotation,  or  widening,  which  can  only  be  accu- 
rately and  correctly  seen  by  one  who  has  had  much  practice 
in  observing  the  normal  form.  Correct  observation  is  the 
first  essential  in  making  an  examination  to  determine  the 
diagnosis ;  the  indications  for  subsequent  therapeutic 
measures  and  a  successful  result  depend  largely  upon  it. 

By  inspection  we  determine  one  of  the  three  cardinal 
signs,  namely,  the  abnormal  curvature  or  angular  deform- 
ity present ;  manual  examination  gives  us  information 
about  the  other  two  cardinal  signs,  crepitus  and  abnormal 
mobility.  The  difficulty  in  diagnosis  arises  when  these 
three  signs  are  absent,  as  is  often  the  case,  and  we  can  then 

244 


PROPHYLAXIS   IN   SURGERY 

merely  assume  the  probability  of  tlie  existence  of  a  fracture 
by  the  presence  of  the  characteristic  pain  of  a  fracture  and 
extravasation  of  blood,  along  with  the  history  of  the  kind 
of  violence  sustained.  In  doubtful  cases  it  is  safest  to  act 
as  previously  recommended,  and  in  the  interests  of  the 
patient  to  assume  that  a  fracture  exists,  rather  than  to 
exclude  that  possibility  because  the  signs  are  obscure.  A 
fracture  which  has  not  been  diagnosed  and  treated  as  such 
may  cause  most  serious  and  permanent  loss  of  function  ; 
while  a  contusion  or  distortion  which  has  been  treated  as  a 
fracture  will  be  none  the  worse  for  the  treatment. 

In  the  Rontgen  rays  we  possess  nowadays  a  valuable  aid 
to  diagnosis,  but  many  doctors,  especially  those  in  the 
country,  are  unable  to  avail  themselves  of  this  aid,  and 
moreover  it  would  be  a  pity  to  apply  this  method  at  the 
expense  of  our  old  methods  of  examination.  When  the  latter 
fail  us  we  can  call  the  radiograph  to  our  aid,  and  we  may 
use  the  radiograph  to  see  whether  our  therapeutic  measures 
are  correct ;  for  the  rest  it  is  wisest  to  continue  to  employ 
our  classical  methods  of  examination,  and  in  the  interests 
of  the  future  medical  practitioner  to  retain  the  valuable 
faculty  for  keen  observation  and  judgment. 

In  speaking  about  the  treatment  of  compound  fractures 
Volkmann  said,  "  the  first  application  of  the  bandage 
decides  the  fate  of  the  patient  and  determines  the  course 
which  the  wound  will  run  "  :  the  first  half  of  this  sentence 
is  applicable  also  to  simple  fractures.  Even  when  the 
treatment  has  been  correct,  there  are  nevertheless  a  number 
of  cases  in  which  some  deformity  remains  after  the  fracture 
has  united,  or  in  which  union  fails,  yet  it  must  be  acknow- 
ledged that  this  is  sometimes  the  result  of  improper 
treatment.  "We  are  here  concerned  with  finding  out  what 
are  the  sources  of  error  which  prevent  a  perfect  union  of 
the  fracture,  and  will  therefore  consider  in  detail  the  most 
common  mistakes  in  treatment,  especially  in  the  application 
of  the  first  bandages.  This  is  the  more  necessary  because 
patients  with  badly  united  fractures  are  very  apt  to  hold 
the  surgeon  responsible  for  the  deformity. 

The  first  condition  in  the  treatment  of  a  fracture  is  to 

245 


THE   PEEVENTION  OE   DISEASE 

remove  the  deformity  before  applying  the  splint ;  in  other 
words,  to  fit  the  broken  ends  of  the  bone  accurately 
together.  Take  as  an  example  the  commonest  fracture,  at 
the  lower  end  of  the  radius.  If  before  applying  the  splint 
we  do  not  correct  both  the  faulty  "  bayonet  "  position  and 
the  radial  abduction,  we  shall  be  sure  to  obtain  an  oblique 
union  of  the  fracture  and  consequent  great  limitation  of 
movement.  The  kind  of  splint  used  is  of  no  great  import- 
ance, but  it  must  be  exactly  applied  so  as  to  correct,  and  in 
some  cases  even  to  over-correct,  the  deformity.  The  old 
rule  should  be  acted  upon,  and  an  immovable  splint  be  in 
general  applied  only  after  the  swelling  of  the  limb  has 
subsided  ;  and  when  for  other  reasons  this  course  is  not 
possible,  the  splint  should  be  changed  after  five  to  eight 
days,  and  any  remaining  deformity  be  removed.  The 
application  of  a  plaster  of  Paris  splint  immediately  after 
the  occurrence  of  the  fracture,  especially  in  fracture  of  the 
forearm,  brings  with  it  the  danger  of  pressure  or  of  con- 
striction of  the  limb,  because  in  all  cases  of  fracture  some 
swelling  is  certain  to  supervene.  When  the  plaster  of 
Paris  splint  is  applied  one  or  two  days  after  the  occurrence 
of  the  fracture,  when  the  swelling  is  at  its  height,  the 
bandage  becomes  loose  as  the  swelling  subsides,  and  the 
ends  readily  become  displaced.  It  is  therefore  advisable 
to  apply  the  plaster  of  Paris  bandage  either  not  till  two  or 
three  days  after  the  occurrence  of  the  fracture  when  the 
swelling  has  subsided,  or  if  it  must  be  applied  earlier,  to 
change  it  after  eight  or  ten  days. 

These  are  indeed  fundamental  rules  with  which  we  may 
assume  every  surgeon  is  acquainted,  but  they  are  not 
always  carried  out,  otherwise  there  would  not  be  so  many 
badly  united  fractures  which,  providing  there  was  no 
complication  present,  might  have  united  so  as  to  leave  no 
impairment  of  function.  The  hospital  surgeon  who  can 
examine  his  patients  daily,  and  who  daily  applies  plaster  of 
Paris  splints,  and  has  a  great  deal  of  practice  in  making 
plaster  splints  fit  accurately  and  well — by  no  means  an 
easy  matter — may  under  exceptional  circumstances  depart 
from   the   rules   given   above,    but   a   surgeon   in   private 

246 


PROPHYLAXIS   IN    SURGERY 

practice  will  always  do  well  to  keep  strictly  to  the  rules 
laid  down  if  he  would  be  spared  unpleasant  surprises  in 
this  direction. 

In  this  connexion  we  may  say  a  few  words  about  the 
so-called  "  ambulatory  "  treatment,  which  has  in  its  time 
been  regarded  as  a  valuable  method  in  the  treatment  of 
fractures,  but  which  is  not  free  from  certain  dangers  for  the 
patient.  There  are  many  doctors  who  used  this  method 
which  was  so  much  praised,  and  who  only  afterwards,  by 
experience  of  such  cases,  learned  the  disadvantages  inherent 
in  the  method. 

We  cannot  here  thoroughly  go  into  the  technique  of 
the  ambulatory  treatment,  and  must  refer  the  reader  to 
Hoffa's  textbook  on  Fractures  and  Dislocations,  in  which 
the  method  is  minutely  described.  In  many  cases  the 
ordinary  plaster  of  Paris  splint  suffices.  It  should  not  be 
too  thickly  padded,  and  it  is  merely  necessary  that  the 
splint  be  to  some  extent  shaped  to  the  natural  support- 
ing points  of  the  extremity  to  avoid  pressure  on  the 
projecting  parts  of  the  bone  and  all  deformity.  Special 
care  should  be  taken  to  avoid  any  pressure  upon  the 
peroneal  nerve  behind  the  head  of  the  fibula,  otherwise 
paralysis  of  the  nerve  is  apt  to  set  in,  and  it  is  very  difficult 
to  cure.  If  the  technique  of  this  ambulatory  treatment  is 
completely  understood,  it  may  be  recommended  for  fractures 
with  little  displacement  in  the  middle  or  upper  third  of  the 
leg.  On  the  other  hand,  we  strongly  caution  the  surgeon 
against  its  use  for  fractures  of  the  malleoli,  for  our  experi- 
ence has  shown  that  the  dreaded  valgus  position  often 
follows  its  use.  And  we  do  not  recommend  this  treatment 
for  fractures  of  the  femur  ;  even  Krause  has  given  up 
using  it. 

We  consider  a  good  splint  for  walking  is  most  useful  in 
the  treatment  of  intra-capsular  fractures  of  the  neck  of  the 
femur  in  very  old  people.  In  such  patients,  as  we  know  from 
experience,  bony  union  does  not  generally  occur.  On  the 
other  hand,  when  these  old  people  are  confined  to  bed  for  a 
long  time,  there  is  the  danger  that  they  may  get  hypostatic 
pneumonia  and  pressure  sores  which  may  prove  fatal.     Our 

247 


THE  PREVENTION  OF  DISEASE 

rule  is  therefore  to  get  these  patients  up  as  soon  as  possible. 
It  is  best  to  have  a  well  fitting  splint  made  for  them,  with 
a  pelvic  band,  although  the  same  result  may  be  obtained  by 
a  bandage  which  is  jDroperly  applied.  These  patients  should 
be  early  treated  with  massage  and  passive  movements. 

This  brings  us  to  the  modern  method  so  much  employed 
in  the  treatment  of  fractures  at  a  joint,  the  so-called  physical 
method,  first  introduced  by  Lucas  Ohampioniere  and  made 
known  in  Germany  by  the  work  of  Landerer.  Some  frac- 
tures, for  instance  fractures  of  the  patella  or  olecranon, 
may  at  once  be  treated  by  massage  after  a  proper  splint 
has  been  applied.  By  this  method  the  cure  is  hastened 
and  the  troublesome  after  effects,  especially  the  muscular 
atrophy,  are  avoided,  and  the  function  of  the  limb  is 
restored  much  earlier.  As  a  rule,  in  fractures  at  a  joint, 
movement  of  the  joint  may  be  commenced  towards  the  end 
of  the  second  week. 

These  three  main  points  must  be  observed  if  we  are  to 
prevent  the  joint  becoming  stiff:  the  splint  must  not  be 
kept  on  the  limb  longer  than  is  absolutely  necessary,  the 
position  in  which  the  joint  is  placed  must  be  changed,  and 
early  massage  and  passive  movements  must  be  used. 
When  the  nature  of  the  fracture  makes  it  probable  that  a 
stiff  joint  or  even  anchylosis  will  be  the  consequence,  we 
should  in  applying  the  first  splint  place  the  joint  in  a 
position  which  will  least  impair  the  function  of  the  limb. 
For  the  hand  the  best  position  is  slight  dorsal  flexion, 
with  the  forearm  midway  between  pronation  and  supina- 
tion ;  for  the  fingers,  with  the  exception  of  the  thumb  and 
little  finger,  a  slight  degree  of  flexion  ;  for  the  elbow  the 
forearm  should  be  placed  at  an  acute  angle  with  the  upper 
arm ;  for  the  shoulder,  a  slight  degree  of  abduction  of  the 
arm.  For  a  stiff  ankle  joint  the  best  position  is  dorsal 
flexion  at  right  angles  to  the  leg  and  a  slight  degree  of 
varus  ;  a  stiff  knee  can  act  best  when  slightly  flexed  ;  and 
the  best  position  for  a  stiff  hip  joint  is  slight  flexion,  to 
make  sitting  down  easier,  and  slight  abduction  of  the  thigh. 
These  rules  should  be  strictly  followed  not  only  for  fractures 
but  for  all  other  joint  affections  ;  if  they  are  not  followed, 

248 


PROPHYLAXIS   IN  SURGERY 

then  when  the  original  trouble  has  been  cured  the  patient 
has  for  the  rest  of  his  life  to  suffer  the  most  serious  dis- 
advantages from  the  false  position  of  the  joint. 

It  is  not  our  intention  to  go  into  all  the  details  of  the 
treatment  of  fractures,  but  as  an  example  we  will  select 
two,  namely,  fracture  of  the  radius  and  fracture  of  the 
malleoli  (Pott's  fracture),  which  together  make  up  nearly 
one  half  of  all  fractures,  and  will  point  out  how  restoration 
of  function  may  be  obtained  in  the  shortest  time  and 
malunion  prevented. 

The  first  and  most  important  point  in  the  treatment  of 
fracture  of  the  radius  is,  as  with  all  other  fractures,  to 
reduce  the  fracture  properly :  this  can  best  be  done  by 
strong  ulnar  flexion  combined  with  palmar  flexion,  while 
pressure  is  made  against  the  projecting  piece  by  the  two 
index  fingers  so  as  to  bring  it  in  the  plane  of  the  rest  of 
the  radius.  Unfortunately,  the  great  number  of  fractures 
which  have  united  with  the  deformity  still  present  shows 
that  many  surgeons  do  not  attempt  to  correct  the  deformity 
or  correct  it  very  imperfectly. 

To  make  sure  of  the  correct  position  it  is  sufficient  to  use 
the  so-called  "  pistol  splint,"  which  should  be  so  padded  as 
to  exercise  very  little  pressure  upon  the  site  of  the  fracture 
itself.  By  this  splint  the  hand  is  maintained  in  strong 
palmar  and  ulnar  flexion.  The  fingers  should  be  free  ;  this 
is  most  important  for  elderly  people,  in  whom  stiffness  is 
otherwise  apt  to  remain  for  weeks  and  may  be  very  trouble- 
some to  remove.  For  this  reason  the  splint  should  reach 
only  as  far  as  the  metacarpo-phalangeal  joints,  in  order  that 
the  patient  may  be  able  to  move  freely  all  the  finger  joints 
from  the  very  beginning.  It  is  advisable  to  change  the 
bandage  after  about  six  days,  to  make  sure  that  the  fractured 
bone  is  in  good  position,  and  to  correct  it  if  not.  About  a 
fortnight  after  the  occurrence  of  the  fracture,  if  the  patient 
is  sensible,  massage  may  be  commenced  and  a  spica  only 
applied  to  the  hand  ;  and  every  day  the  muscles  of  the  fore- 
arm should  be  kneaded  and  tapped,  and  the  area  over  the 
wrist  joint  and  the  callus  should  be  stroked.     In  this  way 

249 


THE   PREVENTION  OF  DISEASE 

it  is  possible  to  restore  the  complete  use  of  the  hand  in  the 
shortest  time. 

In  a  fracture  through  the  malleoli,  the  external  malleolus 
or  fibula  is  pressed  towards  the  tibia,  so  that  the  angle 
opens  outwards  while  the  internal  malleolus  is  displaced 
slightly  downwards  below  the  tibia.  This  fracture  can  be 
reduced  by  first  extending  the  foot  in  the  longitudinal  axis 
and  then  bringing  it  into  the  position  of  talipes  varus.  A 
plaster  of  Paris  splint  should  be  applied  while  the  foot  is  in 
this  position,  and  care  should  be  taken  to  maintain  a  slight 
degree  of  varus  while  the  bandage  is  being  applied.  After 
five  or  six  days,  the  bandage  should  be  changed  for  the 
same  reason  as  for  fracture  of  the  radius,  and  two  weeks 
after  the  commencement  of  the  treatment  massage  and 
passive  movements  should  be  begun  and  the  old  splint, 
which  has  previously  been  slit  up  along  both  sides,  should 
be  reapplied.  After  about  three  weeks  the  patients  can  go 
about  without  difficulty,  wearing  a  laced-up  boot.  Formerly 
we  dared  not  even  take  off  the  bandage  so  early,  and  later 
on  we  had  to  devote  our  energy  to  removing  the  stiffness 
and  the  muscular  atrophy. 

All  that  has  been  said  about  simple  fractures  applies  also 
to  compound  fractures  in  general,  though  in  the  latter  the 
treatment  of  the  wound  is  of  the  first  importance.  We 
saw  in  the  earlier  paragraphs  that  the  kind  of  treatment 
adopted  for  such  a  wound  will  decide  the  entire  course  of 
the  case,  and  that  a  mistake  in  the  antiseptic  method  may 
render  the  result  doubtful.  The  treatment  of  wounds  has 
already  been  discussed.  The  same  general  principles  must 
be  followed  in  the  treatment  of  the  wound  in  a  compound 
fracture,  and  infection  of  the  wound  must  be  prevented,  as 
it  would  lead  to  the  most  serious  consequences  in  connexion 
with  the  fracture.  Here  too  very  much  will  depend  upon 
the  way  in  which  the  limb  is  first  dressed ;  this  must  be 
adapted  to  suit  any  operation,  large  or  small,  which  is 
necessary,  and  the  physician  will  be  guided  by  his  previous 
experience  in  deciding  which  is  the  best  method.  As  a 
rule  the  conservative  method  may  be  followed  in  the  so- 
called  punctured  fracture,  provided  that  antiseptic  treat- 

260 


PROPHYLAXIS   IN   SURGERY 

ment  is  possible ;  in  other  cases  the  wound  has  to  be  en- 
larged to  secure  a  free  outlet  for  secretions ;  or  the  fractured 
ends  of  the  bone  have  to  be  resected  in  order  that  good 
union  may  be  obtained.  Certainly  our  successful  results 
with  these  fractures  today  are  numerous  when  compared 
with  those  of  pre-antiseptic  days,  and  we  have  made  con- 
siderable progress  since  Volkmann  first  laid  down  the  prin- 
ciples for  the  treatment  of  compound  fractures. 

These  are  the  most  important  points,  upon  the  whole, 
which  must  be  observed  if  we  would  prevent  faulty  union. 
Very  many  other  points  need  attention  and  these  are 
learned  only  by  the  experience  of  many  years.  We  have 
here  merely  sketched  the  fundamental  principles  upon 
which  every  surgeon  must  act  if  success  is  to  follow.  The 
more  severe  the  fracture  which  has  to  be  treated,  the  more 
will  the  surgeon  see  that  the  best  guarantee  for  good  union 
and  also  for  true  prophylaxis  is  found  in  extensive  know- 
ledge and  ability. 

PROPHYLAXIS  IN  THE  TREATMENT  OF  DISLOCATIONS 

Dislocations  may  be  grouped  according  to  their  etiology 
into  (1)  traumatic,  caused  by  external  violence  or  by 
muscular  action  upon  a  joint  which  was  sound ;  (2)  con- 
genital ;  (3)  spontaneous  or  inflammatory,  which  have 
arisen  in  the  course  of  certain  affections  of  joints.  Trau- 
matic dislocations  interest  us  most,  because  they  require 
immediate  operative  treatment.  In  this  respect  they  may 
be  compared  to  strangulated  hernia,  where  every  hour  of 
delay  in  reducing  the  hernia  or  in  operating  has  most 
serious  consequences.  As  a  rule,  when  a  simple  dislocation 
is  at  once  reduced,  perfect  restoration  of  the  normal  func- 
tion of  the  joint  may  be  expected,  and  this  is  therefore 
one  of  the  most  satisfactory  operations  for  the  surgeon. 
But  if  days  or  weeks  have  elapsed  since  the  occurrence 
of  the  dislocation,  great  difficulties  stand  in  the  way 
of  its  reduction  and  an  operation  may  even  be  necessary, 
and  there  is  less  hope  of  a  complete  restoration  of 
function.  We  have  but  little  to  say  about  dislocations. 
It   was   recognized    much  earlier  than    was  the  case  with 

251 


THE  PREVENTION  OP  DISEASE 

fractures,  that  not  much  good  can  be  done  by  fixing  the 
joint  for  a  long  time,  and  gradually  the  method  which 
combined  the  simplest  possible  bandage  and  early  mas- 
sage and  passive  movements  was  introduced,  with  the 
object  of  early  restoration  of  the  function  of  the  joint  and 
the  prevention  of  stiffness. 

Just  as  abnormal  brittleness  of  bones  predisposes  to 
fractures,  so  too  will  abnormal  weakness  and  relaxation 
of  the  ligaments  predispose  to  dislocations.  Many  people 
who  have  once  had  a  dislocation  of  a  joint  tend  to  get  a 
recurrence  of  the  dislocation  ;  these  cases  might  be  termed 
habitual  dislocations,  as  the  slightest  external  cause  brings 
them  about.  This  is  especially  the  case  with  the  shoulder 
joint  and  the  temporo-maxillary  joint.  Such  patients  must 
wear  a  suitable  bandage  for  years  to  prevent  a  greater 
range  of  movement  than  that  of  which  the  joint  is  capable 
without  becoming  dislocated.  By  this  means  it  is  possible 
to  prevent  dislocation,  and  according  to  our  experience 
to  effect  a  cure  ultimately. 

The  diagnosis  between  dislocation  and  fracture  at  the 
articular  end  of  the  bone  is  generally  easy,  but  in  some 
cases  may  be  very  difficult,  especially  when  there  is  both  a 
fracture  and  a  dislocation.  Fracture  of  the  radius  affords 
us  a  classical  example  of  the  difficulty  of  diagnosis.  In  the 
majority  of  cases  before  the  time  of  Dupuytren,  a  fractured 
radius  was  taken  to  be  a  dislocation  of  the  wrist.  Similar 
mistakes  may  be  made  between  dislocation  of  the  shoulder 
joint  and  fracture  of  the  surgical  neck  of  the  humerus,  or 
between  a  backward  dislocation  of  the  elbow  and  a  supra- 
condylar fracture  of  the  humerus.  There  is  also  a  difficulty 
in  exact  diagnosis  when  small  pieces  of  bone  have  been 
broken  off.  In  complicated  cases  an  exact  examination  is 
indispensable,  and  one  should  not  hesitate  to  use  an  anaes- 
thetic if  the  examination  is  not  possible  otherwise ;  the 
consequences  of  omitting  to  make  such  examination  cannot 
be  repaired  later.  If  the  surgeon  is  in  doubt  about  the 
diagnosis,  he  should  have  a  skiagram  taken  with  the 
Rontgen  rays  in  order  that  the  relation  between  the  parts 
may  be  made  evident. 

262 


PROPHYLAXIS  IN  SURGERY 

In  the  treatment  of  dislocations  the  same  principles  apply 
as  in  the  treatment  of  fractures.  Here  too  we  aim  at  early- 
restoration  of  the  functions  of  the  limb,  and  therefore  do 
not  keep  the  part  bandaged  up  for  a  long  time,  but  prevent 
atrophy  of  the  muscles  by  early  massage  and  the  application 
of  electricity,  and  stiffness  of  the  joint  by  early  passive  and 
active  movements.  The  first  thing  to  be  done  in  a  fracture 
is  to  correct  the  deformity ;  in  dislocations  too  the  first 
step  is  to  reduce  the  dislocation.  The  bandage  afterwards 
applied  should  be  as  simple  as  possible  and  should  merely 
restrain  the  movements  of  the  affected  joint. 

To  take  as  an  example  the  most  common  dislocation, 
namely,  dislocation  of  the  humerus,  which  forms  about  fifty 
per  cent,  of  all  dislocations.  It  suffices,  when  the  disloca- 
tion has  been  reduced,  to  apply  a  triangular  bandage  as  an 
arm  sling  and  a  few  turns  of  bandage  round  the  chest.  It 
is  best  to  leave  the  shoulder  quite  free  so  that  massage  may 
be  carefully  employed  during  the  first  few  days  for  the 
extravasation  of  blood,  and  electricity  may  be  applied  to 
the  brachial  plexus.  If  this  is  not  done,  the  bruising  and 
tearing  of  these  nerves  may  lead  to  serious  nutritional 
changes  in  the  deltoid  muscle.  After  a  week,  when  the 
rent  in  the  capsule  has  become  closed,  a  triangular  bandage 
alone  as  a  sling  suffices,  and  light  passive  movements  may 
be  begun ;  in  the  third  week,  stronger  passive  movements 
may  be  used,  one  hand  being  placed  upon  the  shoulder  to 
make  sure  that  the  movements  are  at  the  joint  itself. 
When  the  dislocation  is  complicated  by  a  fracture,  the 
bandage  must  be  more  firmly  applied  and  must  be  worn 
longer,  but  it  is  seldom  advisable  to  wear  it  longer  than  a 
fortnight,  for  otherwise  stiffness  of  the  joint  is  apt  to  set 
in,  especially  in  old  people,  and  it  is  very  difficult  to 
remove. 

If  these  principles  are  followed  it  will  be  possible  in  most 
cases  when  the  dislocation  is  a  simple  one  to  restore  per- 
fectly the  functions  of  the  limb. 


253 


THE   PREVENTION  OF  DISEASE 

II.  PEOPHYLAXIS  IN  INJURIES  THROUGH  ACCIDENTS 

The   Employers'   Liability  Act   in   the   German  empire 
opened   up   a  new   realm   in   surgery,  and  was   a   strong 
incentive  to  etiological  and  therapeutical  study,  especially 
in  relation  to  the  inquiry  into  the  after  effects  of  such 
injuries  and  the  connexion  existing  between  these  after 
effects  and  the  original  injury.     Any  surgeon  today  may 
be  called  upon  to  give  an  expert  opinion  about  a  patient 
who  has  met  with  an  accident,  and  this  compels  him  to 
familiarize  himself  with  this  new  branch  of  surgical  science. 
This  new  branch  has  already  produced  many  offshoots,  and 
there  are  treatises  and  textbooks  which  deal  minutely  with 
the  diseases  and  injuries  which  may  follow  an  accident,  and 
the  danger  of  over  specialization  cannot  be  excluded.     But 
this  must  not  deter  us  from  recognizing  the  great  advan- 
tages which  have  been  the  outcome  of  surgical  efforts  in 
this  direction.     The  desire  not  only  that  the  part  should  be 
healed,  but  also  that  it  might  be  perfectly  restored  to  its 
former  usefulness,  which  was  first  felt  by  the  employers, 
was  afterwards  shared  by  the  medical   men   much   more 
than  had  been  the  case  formerly.      And  thus  during  the 
last  few  years  we  have  seen  arrangements  made  in  the 
large  cities  for  first  aid  in  accidents,  which  are  of  great 
value   to   suffering   humanity.      Further,  we   see  what  a 
great  impulse  has  been  given  to  the  use  of   mechanical 
methods  of  treatment  combined  with  massage.      In  con- 
nexion with  this,  ambulatory  methods  were  introduced  for 
treating  fractures  of  the  lower  extremity,  and  by  means  of 
other  surgical  apparatus  we  are  able  to  protect  the  injured 
part  while  the  patient  gets  the  beneficial  effects  of   the 
movements  of  the  rest  of  the  body  at  a  much  earlier  period 
than  formerly  was  the  case.      The  chief  good  ;^however  of 
this  Employers'  Liability  Act  is  that  the  injured  workman 
is  compelled  at  once  to  seek  medical  advice  and  to  allow 
himself  to  be  treated.     If  he  has  not  complied  with  these 
conditions,  compensation  may  later  be  refused  him.     The 
request  made  by  the  employers  that  the  injured  workman 

should  be  under  their  care  from  the  very  beginning  is  only 

254 


PROPHYLAXIS  IN   SUEGERY 

just.  The  suggestion  that  it  is  not  good  to  put  these 
accident  cases  in  a  special  hospital  because  it  tends  to 
malingering  is  not  to  the  point,  because  this  tendency 
among  injured  persons  in  general  surgical  hospitals  can  by 
no  means  be  excluded.  On  the  other  hand  we  must  not 
overlook  the  advantages  we  possess  in  the  better  equipment 
of  these  special  hospitals  with  apparatus,  and  in  the  better 
general  sanitary  arrangements.  Our  experience  too  is 
that  the  number  of  cases  of  malingering  in  which  symptoms 
are  invented  which  do  not  exist  has  not  increased  in  the 
last  few  years.  Possibly  this  can  in  part  be  explained  by 
the  fact  that  the  methods  used  today  for  the  detection  of 
such  malingering  make  the  practice  more  difficult.  Besides 
we  must  not  undervalue  the  arrangement  which  enables 
the  injured  person  to  be  watched  from  the  very  beginning 
by  the  same  doctor  who  treated  him  immediately  after 
the  accident.  Indeed  it  is  an  excellent  precaution  against 
future  exaggerations  of  his  complaint,  that  the  patient 
knows  he  was  carefully  examined  and  his  case  watched  from 
the  very  beginning  by  the  doctor  who  is  afterwards  called 
upon  to  give  an  opinion  as  to  compensation.  It  often 
happens  that  the  surgeon  gives  an  opinion  which  is  asked 
for  when  the  injured  person  leaves  the  hos^Dital,  and  that 
the  employers'  doctor  gives  a  second  opinion  based  upon 
the  condition  of  the  patient  at  the  time  when  he  sees  him 
and  without  having  had  personal  knowledge  of  the  history 
of  the  case.  To  decide  between  two  opposing  opinions, 
another  authority  is  called  in  and  a  final  opinion  arrived  at 
according  to  the  law,  though  the  patient  was  not  seen  or 
was  only  once  examined.  It  seems  unnecessary  to  point 
out  who  should  be  the  authority  recognized.  When  a 
skilled  surgeon  is  put  at  the  head  of  a  hospital  for  these 
accident  cases,  there  can  surely  be  no  serious  suspicion 
against  him  from  the  medical  point  of  view.  We  rejoice 
in  the  fact  that  the  law  has  provided  means  by  which  ade- 
quate medical  aid  is  forthcoming  from  the  very  beginning, 
and  that  so  far  as  is  possible  the  bad  consequences  of  the 
accident  are  prevented,  and  that  the  former  indifference  in 
the  matter  has  been  replaced  by  excellent  arrangements. 

255 


THE  PREVENTION  OF  DISEASE 

The  prophylaxis  for  injuries  caused  by  the  occupation 
does  not  differ  essentially  from  that  already  mentioned  for 
other  injuries,  and  we  should  only  have  to  repeat  most  of 
what  has  been  already  said  if  we  were  to  go  into  details. 
It  only  remains  for  us  therefore  to  refer  to  certain  special 
arrangements  which  are  directly  or  indirectly  due  to  this 
law  about  accidents,  and  to  apply  them  for  the  purposes 
of  prophylaxis. 

First,  we  must  consider  the  causes  of  such  accidents, 
because  only  an  exact  knowledge  of  these  will  enable  us  to 
prevent  them.  They  are  best  divided  into  internal  and 
external  causes,  of  which  the  former  are  partly  personal 
but  rest  also  partly  upon  an  unfit  condition  of  health. 
Among  the  former  are  included  accidents  which  are  the 
result  of  inattention,  of  carelessness  in  the  working  of 
machines,  disregard  of  well  known  precautions  and  so  on. 
To  prevent  or  at  any  rate  to  reduce  the  number  of  these, 
it  is  necessary  again  and  again  to  draw  attention  to  the 
dangers,  not  only  by  printed  rules,  but  also  from  time  to 
time  verbally ;  by  fines  for  infringement  of  the  rules,  and 
by  strict  supervision  to  see  that  the  rules  are  kept  by 
the  workmen.  They  need  some  training  and  education  to 
observe  these  precautions  at  all  times.  "We  are  convinced 
that  when  this  course  is  adopted  the  number  of  accidents 
will  be  diminished ;  and  that  this  is  possible  is  shown  by  the 
great  differences  in  the  frequency  of  such  accidents  in  the 
same  occupation. 

As  to  the  physical  fitness  of  the  workman,  it  might  easily 
be  determined  by  medical  examination  whether  the  work- 
man's general  constitution  fits  him  for  the  particular  work 
and  should  enable  him  to  do  it  without  injury  to  himself. 
Many  a  workman  is  fit  to  undertake  the  heaviest  work  out 
of  doors  who  could  not  work  in  a  confined  space  without 
injury  to  his  health.  It  is  perhaps  only  a  pious  wish  to 
desire  the  appointment  of  doctors,  especially  in  large  manu- 
factories, whose  aid  should  not  merely  be  sought  when  the 
health  has  already  been  endangered,  but  who  would  regu- 
larly from  time  to  time  examine  the  workmen  as  to  their 
bodily  fitness  for  the  work.      There  is  today  an  humani- 

256 


PROPHYLAXIS  IN  SURGERY 

tarian  tendency  which  might  easily  be  diverted  into  this 
channel,  just  as  the  aj^pointment  of  doctors  to  schools  will 
be  generally  adopted  when  the  government  is  convinced  of 
the  utility.  There  are  plenty  of  young  doctors,  especially 
in  large  towns,  who  would  gladly  devote  their  leisure  time 
to  this  useful  work  without  requiring  much  remuneration. 

Among  external  causes  of  accidents,  those  which  are 
general  come  first,  such  as  unfavourable  conditions  of  the 
weather ;  the  influence  too  of  holidays  and  Sundays  must 
not  be  underestimated,  and  is  most  marked  in  the  building 
trade  where  a  large  number  of  accidents  occur  on  Mondays, 
and  the  chief  factor  at  work  in  this  is  alcohol.  It  is  super- 
fluous here  to  go  into  details  about  the  injurious  effects  of 
the  excessive  use  of  alcohol,  and  we  must  also,  on  account 
of  the  small  space  at  our  disposal  in  this  work,  refrain  from 
mentioning  the  measures  which  should  be  taken  against 
this  abuse  of  alcohol.  The  question  has  been  thoroughly 
discussed  in  all  its  relations  by  doctors  and  by  the  public, 
and  the  old  o|)position  still  exists  from  time  to  time  between 
the  advocates  of  total  abstinence  and  those  who  preach  a 
moderate  use  of  alcoholic  liquors.  But  these  theoretical 
considerations  are  beside  the  point  when  we  want  to  help 
the  workman,  and  it  becomes  then  necessary  to  supply  him 
with  substitutes  for  the  alcohol,  by  improving  his  position, 
by  ameliorating  the  domestic  arrangements  made  for  him, 
by  providing  public  amusements,  free  baths,  libraries  and 
coffee  houses.  The  workman  who  during  the  week  has  to 
work  hard  should  have  opportunities  afforded  him  of  getting 
recreation  at  no  great  cost  and  with  ease,  so  that  he  may 
not  seek  relief  in  the  sorrow-killing  but  dangerous 
alcohol. 

Among  the  special  causes  of  accidents  are  those  which 
are  peculiar  to  certain  trades.  The  accidents  in  engineering 
are  different  "from  those  in  textile  manufactures,  and  these 
are  both  different  from  those  in  the  building  trade,  and 
general  statistical  tables  have  been  drawn  up  by  the  various 
societies.  Very  large  numbers  are  dealt  with  in  these 
tables,  and  as  they  contain  interesting  data  about  the  chief 
causes  of  accidents,  a  few  of  the  numbers  will  now  be  given. 

257  s 


THE  PREVENTION  OF  DISEASE 

In  the  year  1898  there  were  6,042,618  persons  insured  by 
sixty-five  trade  societies ;  41,746  of  these  met  with  acci- 
dents, that  is  6 '91  injured  workpeople  per  1,000 ;  in 
agricultural  pursuits  the  injured  men  were  4*06  per  1,000. 
The  causes  of  these  accidents  among  the  men  injured  are 
given  as  follows :  dangerous  nature  of  the  occupation, 
44-36  per  cent.  ;  carelessness  or  inattention,  1649  per  cent. ; 
neglect  of  precautions,  10"50  per  cent.  Among  the  women 
employed  the  numbers  given  are  :  dangerous  nature  of  the 
occupation,  18*92  per  cent.  ;  acting  against  regulations, 
18"60  per  cent.  ;  carelessness,  16*64  per  cent.  ;  neglect  of 
precautions,  14*19  per  cent.  The  differences  in  these 
numbers,  especially  as  to  the  dangerous  nature  of  the 
occupation,  shows  the  greatest  proportion  among  men, 
while  the  workwomen  would  seem  to  be  more  apt  to  break 
rules  ;  greater  supervision  is  therefore  required  and  should 
be  provided.  Neglect  of  precautions  on  an  average  causes 
about  16  per  cent,  of  the  accidents,  which  is  still  a  high 
percentage,  and  might  be  considerably  reduced  if  not 
altogether  avoided  by  better  arrangements. 

The  time  of  the  day  also  exercises  some  influence  upon  the 
occurrence  of  accidents.  They  are  most  frequent  towards 
the  close  of  the  day  when  bodily  fatigue  predisposes  to 
them  or  when  the  remaining  work  which  has  to  be  done  on 
that  day  leads  to  haste  and  so  to  want  of  caution  and  its 
consequences.  These  accidents  also  can  only  be  prevented 
by  careful  supervision  and  careful  regulation  of  the  work. 
From  investigations  as  to  causal  connexion  between  the 
accident  and  the  injury  a  number  of  new  facts  have  been 
ascertained  about  etiology,  and  we  will  give  a  few 
examples,  explaining  them  in  so  far  as  they  can  be  met 
by  prophylactic  measures.  Perfectly  healthy,  strong  and 
generally  quite  robust  men  sometimes  sustain  a  fracture 
when  at  work,  which  is  entirely  caused  by  some  definite 
condition  of  their  work.  These  fractures  mostly  occur 
when  a  heavy  load  is  being  moved  and  some  strong  or 
clumsy  bodily  movement  is  made ;  this  cause  of  fracture 
is  generally  met  with  in  men  who  carry  heavy  weights 
upon    the     shoulder    or    back.      These    have    nothing    in 

268 


PROPHYLAXIS  IN   SURGERY 

common  witli  spontaneous  fractures,  where  the  bones  are 
affected,  and  would  not  have  otherwise  occurred,  so  we 
may  assume  that  the  heavy  weight  supported  by  the  body 
was  the  essential  condition  for  the  occurrence  of  this  frac- 
ture. It  is  an  evidence  that  a  fracture  may  be  caused 
entirely  by  muscular  action,  and  we  should  always  warn 
these  carriers  of  heavy  weights  of  the  danger  they  run 
when  they  make  the  slightest  incautious  movement. 

In  connexion  with  the  suggestion  we  made  above,  that 
workmen  should  from  time  to  time  be  medically  examined, 
the  occurrence  of  spontaneous  fractures  is  instructive,  in 
cases  of  tuberculosis,  syphilis  and  tabes.  We  will  select 
two  typical  cases  from  Golebiewski's  Atlas,  which  will  show 
us  how  such  fractures  are  to  be  prevented. 

In  one  case  a  bricklayer  thirty-four  years  of  age  when 
lifting  a  box  of  lime  felt  a  "  crack  "  in  his  back.  Examina- 
tion showed  the  presence  of  a  fractured  lumbar  vertebra, 
and  the  cause  was  tuberculosis. 

In  the  second  case  a  plasterer  forty-six  years  of  age 
twisted  his  ankle  when  carrying  half  a  sack  of  plaster  on 
his  back  and  sustained  a  fracture  of  the  ankle,  which  pro- 
duced severe  disease  of  the  joint.  The  diagnosis  was  a 
fracture  of  the  malleoli,  and  the  cause  was  tabes. 

There  are  numerous  similar  cases  in  the  literature  of 
accidents.  We  need  only  glance  through  the  chapter  on 
this  subject  in  Thiem's  handbook,  in  which  well  marked 
local  or  a  general  constitutional  disease  is  given  as  the 
direct  cause  of  the  accident.  If  these  diseases  had  pre- 
viously been  diagnosed  by  medical  examination  these 
fractures  might  have  been  prevented,  quite  apart  from 
the  fact  that  in  cases  of  advanced  disease  heavy  work 
should  not  be  permitted.  In  tuberculosis  of  bone,  which 
often  runs  a  very  chronic  course,  much  may  be  done  by 
suitable  supporting  splints  and  other  contrivances  to  pre- 
vent complete  destruction  of  the  joint  and  its  resulting 
deformities.  In  syphilis  too  the  workman  would  save 
himself  much  trouble  if  he  did  not  purposely  conceal  the 
disease  so  long.  This  is  partly  also  the  consequence  of 
that  unfortunate  regulation  which  excludes  persons  suffer- 

259 


THE  PREVENTION   OF  DISEASE 

ing  from  venereal  disease  from  any  help.  Yet,  when  a  bone  is 
already  affected  with  tertiary  syphilis  a  small  injury  often 
suffices  to  cause  a  fracture  at  that  spot,  and  the  workman 
must  be  compensated,  since  he  can  claim  compensation  for 
an  accident  which  has  aggravated  his  previous  disease. 
On  the  other  hand  years  may  have  elapsed  between  the 
venereal  affection  and  the  development  of  tertiary  symp- 
toms, and  it  may  not  be  possible  to  prove  the  connexion 
between  them. 

It  would  take  too  long  to  give  many  other  examples  of 
cases  which  prove  the  importance  of  the  prevention  of  these 
accidents  by  early  examination  of  the  workmen  before  they 
think  they  are  ill,  but  we  will  give  one  example  to  show 
that  this  is  in  the  interests  of  the  trade  societies  also.  It 
is  well  known  that  differences  of  opinion  may  arise  about 
the  traumatic  origin  of  herniae,  at  least  every  case  is 
critically  investigated  in  this  respect  because  we  never 
know  beforehand  whether  the  workman  had  a  hernia 
before  the  accident,  and  it  is  often  very  difficult  to  deter- 
mine whether  the  hernia  has  been  acutely  produced  or  not. ' 
Thiem  in  his  handbook  therefore  says:  "Because  of  the 
vexed  question  about  hernia  it  is  the  duty  of  the  surgeon 
who  has  to  examine  and  to  treat  accident  cases  to  examine 
the  abdomen  in  every  case  of  injury,  without  exception, 
whatever  may  be  the  nature  of  the  injury.  In  this  way 
many  useless  contentions  are  avoided,  and  we  urgently 
advise  the  directors  of  medico-mechanical  institutions  to 
examine  every  patient  for  hernia  upon  his  admission  into 
the  institution.  This  will  also  prove  that  the  assertion 
often  made  by  such  patients  is  incorrect  when  they  state 
that  the  hernia  was  caused  by  the  exercises  prescribed." 
This  caution  would  certainly  not  have  been  given  had  not 
the  experience  of  Thiem  and  of  all  other  surgeons  shown 
that  workmen  avail  themselves  of  every  chance  to  assert 
that  the  hernia  was  caused  by  an  accident  and  thus  claim 
compensation.  If  surgeons  were  appointed  to  examine  the 
workmen  regularly  the  number  of  these  cases  of  deception 
would  be  considerably  reduced. 

The  examination  and  treatment   of   persons  who   have 

260 


PROPHYLAXIS   IN   SURGERY 

sustained  accidents  must  be  according  to  the  fundamental 
rules  already  laid  down.  The  fact  that  the  consequences  of  an 
accident  must  be  borne  by  the  society,  who  value  accurately 
the  capacity  for  work,  and  whose  own  interest  lies  in 
seeing  that  the  patient  has  early  and  adequate  treatment, 
has  had  very  good  results,  especially  in  the  rendering  of 
first  aid.  Means  of  transport  for  injured  persons  have 
marvellously  increased  during  the  last  few  years  in  large 
towns,  as  also  has  the  erection  of  stations  with  appliances 
where  the  first  dressing,  which  is  so  important,  may  be 
applied  by  surgeons  after  a  thorough  examination  has  been 
made,  and  this  should  include  examination  of  the  whole 
body.  In  accident  cases  many  instruments  are  required, 
in  order  that  conclusive  evidence  may  be  given  for 
the  estimation  of  the  compensation.  In  addition  to  the 
ordinary  linear  measure  we  need  an  instrument  to  measure 
exactly  the  range  of  movements  at  the  joint  or  the  angle 
of  an  anchylosed  joint  or  contracted  limb ;  also  callipers  to 
measure  the  diameters  of  limbs  and  a  dynamometer  to 
determine  the  grasp  and  strength  of  the  hand.  These 
exact  measurements  are  very  important  but  should  always 
be  accompanied  by  a  minute  description  of  the  local  con- 
dition of  the  injured  part,  otherwise  they  are  apt  to  lead  to 
erroneous  conclusions.  For  example  the  mere  statement 
that  the  circumference  of  the  affected  limb  is  reduced  or 
increased  tells  nothing  if  we  do  not  add  it  is  caused  by 
oedema,  or  whether  there  is  muscular  atrophy,  or  whether 
both  conditions  are  present.  We  have  often  opportunities 
of  seeing  opinions  given  where  these  points  are  not  suffi- 
ciently regarded  and  too  great  stress  is  placed  upon  figures 
which  in  these  cases  are  of  no  value.  It  is  these  accident 
cases  which  should  make  the  young  surgeon,  here  and  to  a 
certain  extent  in  all  surgical  cases,  not  only  make  a 
thorough  local  examination,  but  also  a  general  examina- 
tion, that  he  may  be  able  to  form  a  correct  opinion  about 
the  patient.  This  is  to  the  advantage  of  the  patient, 
because  the  sooner  a  constitutional  affection  is  discovered 
the  sooner  is  it  possible  to  take  adequate  precautions. 
The  doctor  who  does  not  make  this  general  examination 

261 


THE   PREVENTION  OF  DISEASE 

before  giving  his  opinion  runs  also  the  risk  that  a  later 
opinion — and  there  are  generally  several  opinions — will 
expose  his  neglect.  Our  opinion  is  that  most  weight 
should  be  laid  upon  an  exact  record  of  the  condition 
directly  after  the  injury  ;  in  this  way  only,  when  he  is 
later  called  upon  to  decide  whether  the  consequences  of 
the  accident  coincide  with  the  complaints  of  the  patient, 
can  the  surgeon  give  an  unbiassed  opinion. 

The  after  treatment  is  an  important  consideration  in 
accidents  from  which  the  patient  has  not  recovered  by  the 
thirteenth  week,  or  in  which  the  functions  have  not  yet 
been  completely  restored.  There  however  we  can  no 
longer  speak  about  prophylaxis,  and  must  therefore  refrain 
from  entering  upon  this  interesting  subject.  On  the  whole 
our  impression  is  that  prophylaxis  is  somewhat  neglected 
in  the  treatment  of  accident  cases  ;  yet  it  opens  up  a  wide 
field  of  work  which  will  soon  be  fully  explored. 

III.    PEOPHYLAXIS  IN  THE  TEEATMENT  OF  DEFOEMITIES 

The  oldest  records  of  the  history  of  the  art  of  medicine 
give  us  but  scanty  information  about  the  deformities  of 
the  human  body.  This  is  due  to  the  widespread  custom 
among  ancient  races  of  exposing  weakly  children  or  those 
who  showed  some  defect.  But  even  Galen  uses  a  number 
of  expressions,  such  as  scoliosis,  kyphosis,  lordosis,  and  so 
on,  which  are  still  in  use  today.  The  first  to  introduce 
the  term  orthopaedics  for  the  art  of  curing  deformities  of 
the  body,  and  incorporated  this  branch  of  science  into 
medicine,  was  Andry  (1741).  From  that  time  up  to  the 
present  this  branch  has  been  so  closely  connected  with 
surgery,  and  so  many  famous  surgeons  have  worked  success- 
fully at  the  subject,  that  we  need  only  mention  the  names 
of  Heister,  Grlisson,  Heine,  Dupuytren,  Pott,  Stromeyer 
and  Little,  to  justify  us  in  treating  this  subject  here.  The 
tendency  of  orthopaedics  during  the  last  few  years  has  also 
been  in  the  direction  of  antisepsis  and  asepsis,  and 
only  thus  can  we  safely  undertake  osteotomies,  tenotomies, 
transplantation  of   tendons    and  operations  for  dislocation 

262 


PROPHYLAXIS   IN   SURGERY 

of  the  hip.  Indeed  our  most  important  orthopaedists  con- 
sider that  a  thorough  surgical  education  is  indispensable 
for  successful  work  in  this  field.  In  regard  to  our  prophy- 
lactic measures,  it  is  important  to  state  that  by  far  the 
greatest  number  of  cases  occur  during  the  first  decennium, 
between  the  ages  of  one  and  ten  years.  "We  quote  here  a 
few  interesting  figures  from  the  statistics  given  by  Hoffa 
in  his  work  on  orthopaedic  surgery.  Among  67,919  purely 
surgical  cases  in  the  Munich  Policlinic,  he  found  1,449 
cases  of  deformity ;  that  is  a  percentage  of  2 'IS,  approxi- 
mately equally  distributed  among  males  and  females. 
Ranged  according  to  age  the  numbers  were  : — 

From  0  to  10  years 
From  10  to  20  j^ears 
From.  20  to  30  years 
From  30  to  40  years 
From  40  to  50  years 
From  50  to  60  years 
From  GO  to  70  years 
From  70  to  80  years 

The  chief  point  of  interest  is  the  constant  decrease  in  the 
number  of  cases  with  increasing  years,  and  this  will  be  no 
surprise  to  us  when  we  remember  the  delicate  soft  osseous 
structures  of  childhood.  The  inquiry  whether  the  defor- 
mity was  congenital  or  acquired  gave  the  result  that  150 
cases,  that  is  11*3  per  cent,  were  congenital;  and  1,175 
cases,  that  is  88-7  per  cent,  were  acquired.  For  our  pur- 
pose this  great  excess  of  acquired  cases  over  congenital 
cases  is  important,  because  in  acquired  cases  prophylactic 
measures  might  have  prevented  them,  while  we  are  power- 
less to  do  anything  to  prevent  congenital  cases,  at  least 
those  primary  or  idiopathic  cases  the  causes  of  which  are 
inherent  in  the  germ  of  the  embryo.  In  these  the  external 
cause  is  missing,  while  secondary  congenital  deformities 
may  arise  through  some  external  injury,  although  in  the 
latter  too  an  important  part  is  played  by  pathological 
conditions,  such  as  adhesions  of  the  amnion,  foetal  rickets, 
and  disease  of  the  central  nervous  apparatus.  Here  we  can 
do  nothing  apart  from  strict  observance  of  hygiene  during 

263 


602 

cases 

= 

41-68 

per 

cent. 

481 

cases 

= 

32-32 

per 

cent. 

182 

cases 

— 

12-61 

per 

cent. 

70 

cases 

= 

4-84 

per 

cent 

54 

cases 

= 

3-74 

per 

cent. 

30 

cases 

= 

2-08 

per 

cent. 

28 

cases 

= 

1-59 

per 

cent 

2 

cases 

= 

0-14 

per 

cent 

THE  PREVENTION  OF   DISEASE 

pregnancy,  or  at  most  the  only  treatment  possible  would 
be  to  remove  early  certain  pathological  growths  of  the 
uterus,  which  take  up  room  and  thus  may  tend  to  cause 
deformities.  As  regards  the  inheritance  of  deformity, 
Hoffa  calculates  that  there  was  an  hereditary  predisposition 
in  about  23  per  cent,  of  all  cases,  and  it  often  occurred  that 
the  deformity  first  showed  itself  at  the  same  age  at  which 
the  disease  appeared  in  the  parents.  There  is  reason 
therefore  why  we  should  be  even  more  careful  with  the 
members  of  such  families,  and  should  guard  the  children 
from  all  those  injurious  causes  which  may  give  rise  to  the 
deformity.  Above  all,  preventive  measures  must  be  adop- 
ted as  soon  as  possible  after  birth  when  a  congenital 
deformity  has  been  diagnosed,  in  order  that  increase  of  the 
deformity  may  be  prevented.  During  the  first  year  of  life 
the  soft  osseous  structures  still  permit  of  being  moulded, 
and  at  this  early  age  we  can  often  accomplish  much  more 
than  we  can  later  with  the  most  complex  apparatus.  "We 
must  utter  a  warning  against  the  use  of  apparatus  or 
plaster  splints  which  are  kept  on  for  weeks,  or  even  months. 
The  most  important  point  is  to  bear  in  mind  the  general 
bodily  health,  and  by  massage  and  simple  manipulations  to 
counteract  the  deformity.  By  this  method  we  prevent 
atrophy  which  so  readily  appears  when  splints  are  used, 
and  also  that  troublesome  eczema,  which  may  assume 
dangerous  characters  in  young  children  and  reduce  the 
general  strength.  The  prognosis  in  deformities  depends 
mainly  upon  the  time  when  the  deformity  appeared,  and 
upon  the  degree  of  deformity,  but  it  has  been  observed  in 
cases  where  there  is  an  hereditary  basis  that  the  deformity 
may  increase  after  a  temporary  improvement,  and  caution  is 
especially  needed  in  these  cases  where  the  prognosis  seems  to 
be  made  more  unfavourable  by  the  hereditary  predisposition. 
Our  main  object  from  the  commencement  of  the  deformity 
should  be  to  restore  the  correct  position  by  appropriate 
measures,  so  that  the  growing  osseous  structures  may  be 
developed  according  to  normal  conditions.  It  is  most 
essential,  especially  in  deformity  of  the  lower  extremities, 
which  constitute  a  large  percentage  of  all  deformities,  that 

264 


PROPHYLAXIS   IN  SURGERY 

we  prepare  the  deformed  feet  of  the  child  for  its  first 
attempts  at  walking,  in  order  that  the  weight  of  the  body- 
may  then  help  to  correct  the  deformity,  instead  of  still 
further  increasing  it. 

Among  acquired  deformities  we  shall  for  the  present 
omit  those  primary  or  traumatic  cases  which  are  commonly 
the  result  of  fractures  and  dislocations,  and  shall  refer  to 
them  later.  The  secondary  so-called  "  weight  deformities  " 
are,  as  their  name  implies,  developed  as  the  result  of  the 
effect  of  the  body  weight,  or  of  some  other  pressure  and 
strain.  This  shows  the  direction  in  which  we  must  work 
if  we  would  reduce  the  number  of  cripples,  who  it  has  been 
estimated  number  in  Germany  500,000  approximately.  In 
this  treatment  of  deformities  a  wide  field  of  usefulness  is 
opened  up  to  the  family  physician,  which  is  the  more 
hopeful  when  we  remember,  as  already  pointed  out,  that 
the  prognosis  is  far  better  for  cases  which  have  been 
treated  early.  In  most  cases  unfortunately  medical  treat- 
ment is  not  commenced  sufficiently  early ;  sometimes 
because  the  child's  relatives  have  not  noticed  the  deviation 
of  the  shape  from  the  normal,  sometimes  because  the 
anxious  mother  really  takes  the  child  to  the  doctor  at  the 
very  beginning,  but  goes  home  consoled  with  the  opinion 
"  the  child  will  grow  out  of  it."  Here  we  must  state 
definitely  that  spontaneous  cure  of  an  existing  deformity  is 
the  rarest  occurrence,  and  must  always  be  regarded  as  very 
exceptional. 

To  answer  the  question,  how  can  we  best  remove  these 
deformities  of  bones,  or  better  still,  how  can  we  prevent 
them  ?  it  is  necessary  first  to  be  quite  clear  as  to  the  way 
in  which  they  are  brought  about,  and  the  causes  which 
have  been  at  work.  It  is  not  our  intention  to  discuss  the 
theories  advanced  by  Hueter  and  Volkmann  on  the  one 
side,  and  by  Julius  Wolff  on  the  other,  but  it  is  at 
least  certain  that  these  deformities  are  developed  under  the 
action  of  physical  laws,  and  just  as  the  internal  architec- 
tural structure  of  normal  bones  is  mathematically  accord- 
ing to  the  laws  of  statics,  so  too  the  internal  structure  of 
pathological  forms  is  in  accordance    with   the  same  laws, 

265 


THE   PEEVENTION  OF  DISEASE 

and  this  explains  to  us  a  large  number  of  cases  of  patholo- 
gical changes  in  bones  and  joints.  And  when  we  see  the 
different  mechanical  causes  which  injure  the  osseous  devel- 
opment in  individual  cases,  we  cannot  but  assume  that 
there  are  certain  predisposing  factors  at  work  in  causing 
these  deformities.  Among  such  deformities  are  those  met 
with  in  men  who  work  constantly  with  the  body  in 
some  faulty  position.  Thus  we  meet  with  kyphosis  in  men 
who  habitually  carry  heavy  weights,  where  it  is  caused  by 
the  carrying  of  such  weights ;  and  in  bootmakers  and 
weavers,  where  it  is  caused  by  the  constant  bending 
forward  of  the  body.  Scoliosis  is  met  with  in  millers  and 
masons,  who  carry  heavy  weights  upon  one  shoulder. 
Genu  valgum  and  flatfoot  are  seen  in  bakers  and  waiters. 
These  deformities  due  to  occupation  have  been  largely 
ascribed  to  rickets  but  without  any  definite  evidence ; 
and  genu  valgum  and  iiatfoot  which  appear  at  puberty 
have  been  regarded  as  a  special  late  manifestation  of 
rickets.  Occasionally  deformity  appears  in  strong,  robust 
looking  children,  though  as  a  rule  these  skeletal  changes 
appear  in  children  who  are  delicate,  weakly  and  anaemic, 
who  suffer  from  digestive  disturbances,  are  scrofulous, 
and  have  grown  very  fast.  The  family  physician  should 
use  his  influence  with  the  parents  in  order  that  occupa- 
tions may  not  be  chosen  for  them  which  will  favour 
the  appearance  of  deformities  such  as  genu  valgum  and 
flatfoot.  All  occupations  which  require  long  continued 
standing  should  be  forbidden.  In  anaemic  children  we 
must  endeavour  to  raise  the  nutrition  of  the  entire  body, 
and  to  increase  the  formation  of  proteids.  This  is 
best  attained  by  suitable  gymnastic  exercises  combined 
with  massage  and  hydrotherapy,  and  the  regulation 
of  diet,  which  for  children  should  contain  much  milk ;  and 
this  is  far  preferable  to  the  use  of  iron  and  arsenic  prepara- 
tions, although  in  some  cases  we  cannot  dispense  with  the 
latter.  These  measures  are  not  enough  by  themselves,  and 
these  children  should  at  school  be  kept  from  all  influences, 
such  as  bad  posture  in  writing  and  long  continued  sitting 
which  so  frequently  lead  to  deformity.     The  commonest 

266 


PROPHYLAXIS  IN  SURGERY 

deformity  set  up  is  habitual  scoliosis,  wliicli  constitutes 
about  twenty-eight  per  cent,  of  all  cases  of  deformity,  and 
in  the  majority  of  cases  is  developed  between  five  and 
ten  years.  Eulenburg  found  that  among  1,000  cases  of 
scoliosis,  564  cases  appeared  between  the  seventh  and  tenth 
years  of  age ;  that  is  during  the  years  when,  with  the 
commencing  second  dentition,  there  is  a  tendency  to  in- 
creased development  of  the  entire  skeleton.  Eulenburg 
calculates  that  heredity  is  a  factor  in  twenty-five  per  cent. 
among  the  1,000  cases;  not  that  these  children  are  born 
with  scoliosis,  but  the  hereditary  factor  consists  in  this, 
that  the  children  are  born  with  a  certain  relaxation  and 
lack  of  resisting  power  in  the  constituent  parts  of  the 
vertebral  column,  and  in  this  condition  deformity  vastj 
later  be  produced  by  some  slight  external  cause.  The  act 
of  writing  must  be  regarded  as  one  of  the  most  important 
of  these  causes  when  combined  with  the  predisposing 
factors  above  alluded  to,  partly  constitutional  weak- 
ness, and  partly  weakness  of  the  bones  themselves,  the 
aetiology  of  which  is  still  unknown.  During  late  years 
many  school  desks  have  been  devised  to  try  to  remedy  the 
faulty  posture  assumed  by  children  in  writing.  But  by 
this  we  shall  not  be  able  to  prevent  the  tired  body  from 
again  adopting  a  crooked  position.  In  addition  to  school 
hygiene,  and  this  disease  has  been  called  sedentary  or 
school  disease,  preventive  measures  should  aim  at  prevent- 
ing any  real  tiredness.  This  can  be  best  done  by  restrict- 
ing the  number  of  school  hours,  and  above  all  by  adequate 
intervals  between  the  lessons,  during  which  the  relaxed 
muscles  may  be  again  strengthened  by  exercise  in  the 
fresh  air.  In  addition  there  should  be  for  both  sexes,  regu- 
lar gymnastic  exercises  acting  upon  the  vertebral  column, 
and  strengthening  the  whole  muscular  system,  and  espe- 
cially the  muscles  of  the  back.  Gymnastic  games  are 
especially  beneficial,  and  have  gradually  spread  from 
Gorlitz  to  other  places.  Growing  girls  should  have  physi- 
cal exercise ;  for  example,  playing  with  balls,  swimming 
and  skating.  Care  of  the  skin  must  not  be  neglected, 
especially  of  the  back,  and  neglect  to  cleanse  the  skin  by 

267 


THE  PREVENTION  OF  DISEASE 

friction  and  baths  is  still  very  common  among  us,  but  we 
are  endeavouring  to  remedy  this  by  providing  public  baths, 
which  put  this  luxury  within  the  reach  of  the  poorest 
classes.  It  is  to  be  hoped  that  in  course  of  time  such 
institutions  will  be  available  free  of  charge  for  the  mass  of 
the  people. 

To  see  whether  these  endeavours  protect  our  youth 
against  the  injurious  effects  of  school,  school  doctors  will 
be  appointed^ — it  is  merely  a  matter  of  time — and  by 
examining  the  children  several  times  a  year,  they  will  re- 
cognize commencing  deformities,  and  the  necessary  steps  will 
be  at  once  taken  to  prevent  them.  And  when  in  the  future 
the  changes  which  the  doctors  recommend  are  carried  out  at 
schools,  and  the  physical  health  of  these  children  is  not 
sacrificed  to  their  intellectual  development,  but  the  two 
work  harmoniously  together,  then  children  will  later  be 
equal  to  their  future  occupations,  and  their  minds  will 
develop  better  when  their  physical  health  is  good  than  when 
an  erroneous  method  of  education  has  weakened  the  body. 

Still  one  other  factor  in  the  causation  of  deformities  must 
be  considered,  namely  rickets,  a  disease  in  which  a  defec- 
tive deposition  of  lime  salts  in  growing  bones  interferes 
with  their  proper  function.  It  appears  mostly  during  the 
second  year  of  life,  at  the  time  when  active  growth  of  the 
osseous  structures  takes  place.  As  a  result  the  bones  be- 
come weak,  and  deformity  of  the  skeleton  is  developed. 
Rickets  is  the  commonest  disease  in  children,  and  exists  all 
over  the  world,  though  it  is  much  rarer  in  tropical  and  sub- 
tropical districts  than  in  northern  countries.  The  disease 
is  produced  by  unfavourable  external  conditions,  and  is  met 
with  therefore  not  only  among  the  people  in  large  towns, 
but  also  in  the  country,  where  the  small  close  damp  rooms 
are  injurious  to  health.  But  the  chief  predisposing  cause 
is  the  faulty  diet  of  children.  Sometimes  it  is  improper 
diet,  which  predisposes  to  rickets  by  setting  up  chronic 
digestive  troubles  ;  sometimes  it  is  insufficient  food.  Arti- 
ficial foods  are  a  very  great  causative  factor,  especially 
when  they  are  used  as  substitutes  for  milk  diet,  as  often 
is    the    case   among   the   lower   classes,    and   cocoa,   coffee 

268 


PROPHYLAXIS  IN  SURGERY 

and  starcliy  foods  are  given  to  children.  Severe  acute 
diseases  are  also  unfavourable  conditions,  and  congenital 
syphilis  is  regarded  by  many  as  a  causative  factor  in 
rickets. 

At  present  we  have  no  statistics  showing  the  number  of 
cases  of  deformity  in  which  rickets  was  a  cause,  but  there 
is  no  doubt  that  rickets  plays  a  large  part  in  the  aetiology 
of  deformities.  Kassowitz  found  that  among  5,000  cases 
of  rickets  nearly  every  case  showed  more  or  less  clearly  the 
deformity  known  as  "  pigeon  breast."  Among  1,444  cases 
mentioned  by  Ho£fa,  there  were  39  cases  of  rachitic 
kyphosis,  that  is  2-07  per  cent. ;  107  cases  of  rickety  curva- 
ture of  the  leg,  that  is  741  per  cent. ;  and  among  the  119 
cases  of  genu  valgum  doubtless  a  large  number  had 
suffered  from  rickets  in  youth.  Among  859  orthopaedic 
cases  treated  by  Dollinger  there  were  72  rickety  curvatures 
of  the  leg,  or  8'4  per  cent.  According  to  Gruerin,  rachitic 
scoliosis  occurs  in  9'7  per  cent,  of  all  rickety  children. 

To  ensure  a  proper  diet  for  children  during  the  first  nine 
months  of  life  is  the  best  prophylactic  measure  against 
rickets  which  a  doctor  can  take.  The  child  should  not  be 
overfed,  and  the  breast  should  be  given  in  accordance  with 
the  well  known  rules.  Unfortunately  the  artificial  feeding 
of  children  is  becoming  more  and  more  common,  even 
among  the  poorer  classes,  and  we  should  make  every  effort 
to  see  that  children  are  breast  fed,  especially  when  no  contra- 
indication exists.  If  artificial  feeding  cannot  be  avoided, 
cow's  milk  is  the  best  substitute  for  the  breast,  and  should 
be  given  mixed  with  varying  proportions  of  water  or  of  veal 
broth,  according  to  the  condition  and  age  of  the  infant. 
All  other  methods  of  artificial  feeding  should  be  avoided, 
especially  when  rickets  already  exists,  and  also  the  addition 
of  much  sugar  or  starch.  Special  care  should  be  given  to 
the  digestive  organs,  because  chronic  dyspepsia  and 
intestinal  catarrh  which  have  existed  for  long,  either  cause 
rickets  or  aggravate  the  disease  if  it  already  exists.  The 
distended  abdomen  of  such  children  points  to  the  meteorism 
which  is  never  absent  in  rickets  and  to  the  habitual  con- 
stipation.    These  children  should  be  much  out  in  the  fresh 

269 


THE  PREVENTION   OF  DISEASE 

air,  and  to  prevent  curvature  of  the  spinal  column,  should 
not  be  carried  on  the  arm,  but  lie  on  a  horsehair  mattress. 
General  massage  of  the  body  is  very  useful  for  these 
digestive  disturbances,  when  it  is  combined  with  washing 
in  cold  water  and  friction.  By  this  method  the  skin  is  main- 
tained in  a  good  condition.  Baths  may  also  be  used  with 
the  addition  of  brine  or  of  Kreuznach  salts,  or  of  some  of 
the  well  known  salts  of  Orb,  Kosen,  Stassfurt,  or  Sodenthal. 
By  these  baths  a  derivative  action  of  the  skin  is  obtained, 
and  the  skin  should  become  red  if  the  proper  effect  is  to  be 
obtained.  If  circumstances  permit  these  children  should 
be  sent  to  a  place  where  there  are  brine  baths,  or  still 
better  where  there  are  sea  baths.  Associations  exist  to 
provide  such  a  holiday  for  the  poorer  children,  and  this  is 
spreading  from  year  to  year,  though  much  more  still 
remains  to  be  done  in  this  direction.  Homes  for  cripples, 
which  have  been  established  during  the  last  decade,  are 
also  most  useful ;  but  these  cripples  are  to  a  certain  extent 
cut  off  from  the  rest  of  the  world,  and  they  are  apt  to  feel 
that  they  are  looked  at  askance  ;  and  this  gradually  leads 
to  a  bitterness  in  their  character. 

To  prevent  such  deformities  by  carrying  out  the  general 
principles  sketched  above  is  the  most  grateful  task  of  the 
surgeon,  especially  when  we  remember  that  in  spite  of 
great  advances  made  in  the  last  few  years  and  of  the  intro- 
duction of  mechano- therapy,  a  well  marked  deformity  often 
takes  years  to  cure,  and  it  may  even  be  impossible  to  restore 
perfectly  the  normal  form  of  the  body. 

IV.    PEOPHYLAXIS  IN  THE  TKEATMENT  OE  TUMOUES 

Cohnheim's  sentence,  "  If  there  is  one  chapter  in  our 
science  which  is  still  veiled  in  darkness  it  is  that  of  the 
aetiology  of  tumours,"  is  still  true  today,  and  we  are  still 
unable  to  say  what  is  the  real  cause  of  carcinoma  and  other 
tumours,  though  much  work  has  been  done  in  this  subject. 
Yet  it  is  a  consolation  that  we  have  learned  certain  of  the 
jiredisposing  causes  of  carcinoma  which  are  constantly 
met  with,  and  have  therefore  caused  us  to  attach  much 

270 


PROPHYLAXIS  IN   SURGERY 

importance  to  them.  "We  mean  the  mechanical  and  chemical 
injuries  connected  with  certain  occupations.  The  best 
known  are  the  tar  cancer  and  chimney  sweepers'  cancer 
among  workmen  at  the  tar  and  paraffin  industries  and 
chimney  sweepers.  We  will  give  a  few  other  striking 
instances  of  the  aetiological  significance  of  irritation 
leading  to  chronic  inflammation  upon  the  occurrence  of 
carcinoma.  Bottini  mentions  100  cases  of  cancer  of  the 
tongue  which  he  had  observed  (including  three  cases  in 
women)  which  were  all  caused  by  smoking  and  chewing  of 
tobacco.  H.  Zinker  found  gall  stones  in  84-5  per  cent.,  and 
Birch-Hirschfeld  in  91-7  per  cent,  of  cases  of  primary  carci- 
noma of  the  gall  bladder,  and  these  stones  are  known  to 
give  rise  to  irritation  and  inflammation. 

If  we  glance  through  the  statistics  of  cancer  of  the 
breast  hj  Winiwarter  and  Oldekop  we  find  that  in  125  out 
of  934  cases  some  trauma  had  occurred — that  is  in  13-4  per 
cent,  of  the  cases.  Unfortunately  the  many  sources  of 
irritation,  especially  of  internal  organs,  can  only  be  pre- 
vented if  we  remove  early  enough  the  condition,  which  we 
know  may  in  course  of  time  lead  to  the  development  of  a 
malignant  growth. 

Every  form  of  benign  tissue-hyperplasia,  such  as  con- 
genital naevus,  papilloma,  atheroma,  adenoma,  gumma, 
may,  if  exposed  to  constant  mechanical  or  chemical  irrita- 
tion, pass  over  into  a  carcinoma,  though  we  cannot  say  the 
exact  time  when  the  change  began;  scars  too  of  very 
various  origin  are  a  favourable  soil  for  malignant  tumours. 
According  to  Rapock  182  out  of  399  cases  of  carcinoma  of 
the  skin  arose  from  warts.  It  is  these  occasional  causes 
which  we  must  oppose  with  all  the  means  at  our  disposal. 
We  must  advise  the  removal  of  benign  tumours,  especially 
those  which  show  even  the  very  least  tendency  to  increased 
growth  or  which  are  situated  in  places  where  they  are 
exposed  to  constant  irritation.  We  must  warn  against  the 
scratching  of  warts,  and  against  cutting  them  with  septic 
knives,  and  should  see  that  sharp  pieces  of  teeth  and  bad 
teeth  are  removed.  In  chronic  states  of  irritation  of  the 
mucous  membranes  we  must  forbid  smoking  and  chewing  of 

271 


THE  PREVENTION  OF  DISEASE 

tobacco,  and  above  all  the  abuse  of  alcohol,  which  experi- 
ence has  shown  ns  gives  rise  to  carcinoma  of  the  oesophagus 
and  of  the  stomach. 

"We  must  point  out  the  dangers  of  the  pressure  by  corsets, 
which  are  a  cause  of  mammary  cancer  and  of  obstruction  in 
the  portal  circulation,  and  may  tend  to  the  formation  of 
gall  stones,  the  causal  significance  of  which  in  the  develop- 
ment of  malignant  tumours  has  been  mentioned  above. 
Chronic  eczema  of  the  skin  should  be  carefully  treated,  and 
workmen  in  tar  and  paraffin  factories  and  chimney  sweeps 
should  be  warned  of  the  danger  which  threatens  them.  It 
has  been  shown  that  congenital  phimosis  tends  to  the 
development  of  cancer,  and  early  operation  should  be  recom- 
mended. An  endeavour  should  also  be  made  to  heal  old 
ulcers  of  the  leg,  which  often  afford  a  favourable  opportunity 
for  the  development  of  carcinoma. 

"When  we  review  these  occasional  causes  the  question 
rises  in  our  minds,  How  is  it  to  be  explained  that  the 
number  of  cases  of  malignant  tumours  is  small  compared 
with  the  frequency  of  the  occurrence  of  the  irritations  and 
injurious  effects  mentioned  above  ?  This  is  a  problem 
which  the  theories  of  Virchow,  Cohnheim,  Waldeyer, 
Grawitz  and  Klebs  have  not  yet  solved.  This  is  not  the 
place  to  discuss  these  theories,  yet  we  must  refer  to  one 
factor  which  has  perhaps  hitherto  not  received  sufficient 
attention — the  heredity  of  carcinoma,  or  rather  the  disposi- 
tion to  it.  To  give  a  few  statistics,  according  to  Winiwarter 
6  per  cent,  of  the  cases  of  carcinoma  are  hereditary  ;  accord- 
ing to  Brautigam,  8*5  j)6r  cent. ;  according  to  PfeiJffer,  9"3 
per  cent. ;  and  according  to  Ziel,  11  per  cent.  In  Ziemssen's 
"Handbook  of  Pathology  and  Therapeutics"  192  out  of  1,137 
cases  had  a  family  history  of  cancer.  And  though  we  con- 
fess that  the  heredity  cannot  always  be  proved  in  a  family 
and  that  little  weight  can  be  placed  upon  the  statements  of 
patients  when  medical  information  is  not  forthcoming,  yet 
we  cannot  but  regard  heredity  as  an  aetiological  factor,  and 
in  families  where  there  is  this  hereditary  taint  the  greatest 
care  should  be  taken  to  avoid  all  the  injurious  conditions 
and  occasional  causes  described  above. 

272 


PROPHYLAXIS   IN  SURGERY 

While  we  know  so  little  about  the  real  cause  of  tumours, 
we  shall  not  be  able  to  do  much  to  prevent  them  in  spite  of 
all  our  efforts.  In  the  present  state  of  our  knowledge  we 
can  only  successfully  combat  the  disease  by  removing  every 
benign  tumour  as  soon  as  possible,  since  it  is  possible  a 
benign  tumour  may  become  malignant,  though  it  is 
impossible  to  tell  when  the  change  began  or  what  caused 
it.  The  next  question  that  arises  is  whether  it  is  possible 
today  to  remove  a  malignant  tumour  so  completely  by 
operation,  and  without  danger  to  life,  that  we  may  feel 
sure  it  will  not  spread  or  recur. 

To  answer  this  question  we  take  the  statistics  of  cases 
in  which  cure  is  assumed  to  have  resulted  when,  as 
Volkmann  teaches,  no  reourrence  has  appeared  within 
three  years.  Although  we  know  that  occasionally  recur- 
rence has  been  seen  after  five  to  ten  years,  yet  this  is  after 
all  so  rare  that  for  practical  purposes  and  in  dealing  with 
large  figures,  an  interval  of  three  years  may  be  taken  to 
denote  probable  cure.  "We  select  for  this  purpose  that  part 
of  the  body  which  is  most  accessible  and  has  therefore  been 
most  thoroughly  worked  out,  the  female  breast.  How 
widespread  carcinoma  of  the  breast  is,  may  be  judged 
from  the  following  figures  taken  from  Heimann.  Of  1,234 
operations  on  the  breast,  1,110  were  for  carcinoma,  and 
only  124  for  other  tumours. 

The  essential  conditions  for  a  perfect  cure  are  an  early 
operation  and  the  removal  of  all  the  diseased  tissue.  The 
history  of  mammary  amputation  is  extremely  interesting 
in  this  respect,  and  figures  prove  that  the  number  of  cases 
cured  by  the  operation  has  increased  according  as  investi- 
gations have  advanced  showing  us  the  path  along  which  it 
spreads  and  enabling  us  to  remove  this  diseased  tract.  The 
stages  have  roughly  speaking  been  the  following  :  extir- 
pation of  the  tumour  itself  ;  amputation  of  the  breast ; 
clearing  out  of  the  axilla  ;  removal  of  the  pectoralis  major 
muscle.  At  the  Congress  of  Surgeons  in  1883,  Kiister 
pointed  out  the  importance  of  always  clearing  out  the 
axilla  and  introduced  the  method.  After  further  experi- 
ence Heidenhain's  book  appeared  in  1889,  and  he  recom- 

273  T 


THE  PREVENTION  OF  DISEASE 

mended  that  in  some  cases  the  pectoralis  major  should  also 
be  removed ;  his  researches  showed  the  path  along  which 
mammary  cancer  spreads,  and  that  local  recurrence  pro- 
ceeded in  most  cases  from  cancer  cells  which  had  been 
conveyed  by  lymphatic  vessels  into  the  muscle  itself. 
Following  his  suggestion,  a  number  of  others,  for  example 
Helferich,  Rotter  and  Halsted  have  carried  out  this  method 
of  breast  amputation,  and  their  results,  when  compared 
with  those  previously  published  by  the  best  operators, 
testify  to  the  excellence  of  the  method.  That  what  we 
have  most  to  fear  is  local  recurrence  is  proved  by  numer- 
ous records  of  earlier  years.  Those  of  Hans  Schmidt 
show  that  among  95  cases  of  recurrence,  71  were 
local,  that  is  744  per  cent ;  and  Rotter  found  30  such 
local  recurrences  among  34  cases,  that  is  88-23  per 
cent.  Statistics  collected  by  S.  Gross  show  that  on  an 
average  the  best  results  of  former  years  give  66*8  per  cent, 
cases  of  local  recurrence,  while  the  average  among  the 
results  of  Halsted,  Rotter,  Cheyne  and  Helferich  give  only 
30*3  per  cent.,  or  less  than  half  the  former.  Another 
important  point  to  consider  is  whether  the  greater  extent 
of  the  operation  has  increased  the  danger  of  it.  In  regard 
to  this,  recent  years  show  very  favourable  results,  and  in 
125  consecutive  cases  published  by  Weir,  and  76  by 
Halsted  and  May  only  one  case  of  death  occurred,  and 
this  was  ascribed  to  the  ether,  while  Dennis  had  one 
fatal  result  among  74  cases  and  this  patient  suffered 
from  haemophilia.  It  is  obvious  that  with  extensive 
tumours  there  are  limits  to  successful  operation.  We 
confess  that  it  is  hopeless  to  think  of  operation  for  a  "  cancer 
en  cuirasse,"  neither  would  a  judicious  surgeon  operate 
when  there  were  already  signs  of  pleuritic  irritation.  For 
these  inoperable  cases  there  remains  the  possibility  of 
attempting  a  cure  by  injections  of  bacterial  virus,  although 
the  results  are  not  very  satisfactory.  Friedrich  writes 
about  these  attempts  which  he  carried  out  under  Thiersch  : 
"  With  streptococci  and  mixed  culture  sterilizations  and 
filtrates,  cure  was  not  obtained  when  these  were  injected 
into   the    tissues   of    the   tumour,    whether  carcinoma   or 

274 


PROPHYLAXIS   IN  SURGERY 

sarcoma."  When  however  both  doctor  and  patient  are 
convinced  of  the  hopelessness  of  any  operation,  the  patient 
may  be  advised  to  try  this  method.  It  is  these  hopeless 
cases,  where  operation  is  impossible  because  of  the  extent  of 
the  local  growth,  which  point  again  to  the  importance  of 
early  operation  for  snch  cases.  In  general  we  may  say 
that  the  earlier  the  tumour  is  removed  the  less  extensive 
will  be  the  operation  and  the  greater  the  chance  of  a  cure. 
We  must  therefore  make  a  diagnosis  early,  and  there  are 
many  cases  in  which  this  is  possible.  One  symptom  should 
be  specially  borne  in  mind,  which  is  important  in  malig- 
nant tumours  ;  this  is  haemorrhage,  and  it  appears  com- 
paratively early.  In  every  case  of  haemorrhage  from  the 
rectum  or  vagina,  we  should  ascertain  by  palpation 
whether  there  is  any  special  cause  for  it,  and  we  must  not 
hesitate  to  make  a  vaginal  examination,  even  though  it 
possibly  turns  out  to  be  only  menorrhagia  or  haemorrhage 
from  haemorrhoids.  In  haemorrhage  from  the  stomach 
too  one  should  avail  oneself  of  every  possible  means  of 
diagnosis  to  avoid  a  mistake  in  this  difEcult  matter  of  the 
differential  diagnosis  between  simple  ulcer  of  the  stomach 
and  carcinoma. 

A  second  symptom  to  which  great  weight  should  be 
attached  is  emaciation,  which  is  often  so  marked  in  com- 
parison with  the  small  size  of  the  tumour  that  we  cannot 
but  assume  that  serious  nutritional  changes  are  present, 
and  above  all  a  change  in  the  condition  of  the  blood 
though  up  till  now  no  such  change  in  the  blood  has  been 
detected.  This  loss  of  flesh  is  the  more  remarkable  when 
there  has  been  no  loss  of  blood  and  when  the  digestive 
organs  apparently  still  work  well,  and  when  we  remember 
how  commonly  haemorrhages  exist  for  years  in  women 
without  leading  to  any  real  disturbance  of  nutrition.  On 
the  other  hand,  emaciation  with  malignant  tumours  may 
be  regarded  as  the  precursor  of  cachexia  which  with 
certainty  appears  when  the  tumour  has  not  been  removed. 
If  the  tumours  are  situated  near  the  surface  or  upon  an 
osseous  structure,  as  is  the  case  with  most  sarcomata,  then 
it  is  palpable  and  more  easily  accessible,  yet  nevertheless  it 

275 


THE  PREVENTION  OF  DISEASE 

may  present  great  difficulties  in  diagnosis.  In  the 
Rontgen  rays  we  possess  an  additional  means  of  diagnosis, 
yet  here  mnch  depends  upon  the  correct  interpretation 
of  the  photograph,  and  it  will  need  some  years  of  ex- 
perience before  we  can  interpret  skiagrams  correctly  and 
thus  reduce  the  number  of  errors.  The  difficulties  which 
depend  on  the  obscurity  of  the  origin  of  tumours  have 
stimulated  our  most  eminent  inquirers  to  renewed  research, 
and  we  cherish  the  hope  that  these  great  endeavours  will 
prove  successful  in  throwing  some  light  upon  the  subject. 


276 


Prophylaxis  in  the  Diseases   of  Women 

BY 

DR.    0.    SCHAEFFER 

OF   THE    UNIVEESITY   OF   HEIDELBEEG 


277 


Prophylaxis  in  the   Diseases  of  Women 

When  we  consider  tlie  prevention  of  the  diseases  of  women 
from  the  standpoint  of  their  aetiology,  we  are  led  in 
almost  every  case  out  of  the  narrow  range  of  gynaecology 
into  the  wide  field  of  general  internal  pathology — far  more 
indeed  than  is  the  case  when  these  diseases  are  considered 
with  regard  to  their  symptoms  and  pathological  anatomy. 
When  the  diseases  of  women  are  considered  aetiologically, 
the  close  connexion  which  exists  between  the  sexual  system 
and  the  whole  organism  becomes  more  clear  :  the  latter 
appears  no  longer  so  definitely  controlled  by  the  former, 
but  the  two  seem  rather  to  exercise  a  peculiar  mutual 
influence  upon  one  another,  such  as  we  meet  with  in  the 
case  of  no  other  subordinate  organ. 

Briefly  I  might  express  it  thus :  not  only  in  consequence 
of  the  influence  of  the  sexual  system,  but  also  because  of 
the  sexual  functions,  there  arise  through  the  action  of  the 
central  nervous  system  of  ill  developed  individuals  disturb- 
ances of  the  whole  organism,  which  in  a  "  vicious  circle  " 
react  on  the  organs  of  generation. 

Among  these  disturbances,  for  example,  I  would  put  first 
the  anomalies  of  menstruation  and  their  associated  pheno- 
mena, such  as  chlorosis,  anaemia,  gastro-intestinal  disturb- 
ances, anomalies  of  micturition,  diseases  of  the  skin  and 
anomalies  of  perspiration,  hystero-neurasthenic  attacks  and 
other  neuroses.  Next  I  would  place  those  conditions  of 
relaxation  and  of  congestion  of  the  pelvic  and  abdominal 
organs  which  have  been  produced,  not  by  primary  local 
infective  inflammations,  but  by  disturbances  in  the  innerva- 
tion of  all  the  contractile  elements  of  the  generative  organs 

279 


THE  PREVENTION  OF  DISEASE 

and  of  their  ligamentous  and  subperitoneal  connexions  in 
the  pelvis,  principally  therefore  of  the  muscular  tissues 
including  the  muscular  fibres  of  the  blood  vessels.  This 
"  want  of  tone"  leads  in  part  to  the  production  of  descent 
and  of  prolapse  of  the  uterus,  of  the  vaginal  walls  with 
the  bladder  and  rectum,  and  of  the  ovaries,  and  further 
to  general  enteroptosis.  It  leads  also  to  retroversion  and 
flexion  of  the  uterus,  and  sometimes  to  chronic  hyperaemia, 
and  thus  to  vascular  and  lymphatic  engorgement  of  all  the 
abdominal  viscera ;  and  when  there  is  at  the  same  time  a 
want  of  tone  of  the  abdominal  wall,  it  gives  rise  to  disten- 
sion of  the  intestines.  Remoter  results  of  this  hyperaemia 
are  various  inflammatory  conditions  not  produced  by  any 
primary  infection :  these  are  certain  forms  of  chronic 
metritis,  cystic  degeneration  of  the  ovaries,  and  possibly 
also  the  formation  of  fibroids  and  glandular  cysts. 

Almost  without  exception  we  find  in  such  individuals 
other  signs  also  of  general  neurasthenia  and  of  irregularities 
of  metabolism,  which  usually  appear  first  at  puberty  or 
which  become  much  more  marked  at  that  period.  It  is 
therefore  clear  that  the  influence  is  mutual  and  not  one- 
sided. And  it  is  here  that  "preventive  treatment"  has  a 
wide  field,  which  is  recognized  often  neither  by  the  public 
nor  by  the  physician,  and  this  preventive  treatment  is  of 
value  not  only  for  the  patient  herself  but  also  for  her  off- 
spring. Prophylaxis  is  especially  useful  in  these  cases,  because 
these  slowly  progressive  functional  disorders  lead  at  last  to 
structural  changes,  and  thus  make  it  almost  impossible  to 
restore  by  treatment  the  normal  condition  of  the  organs. 

Taking  the  pathology  as  the  basis  of  classification,  we  will 
consider  the  preventive  treatment  of  the  diseases  of  women 
and  of  their  sequelse  under  five  heads — ■ 

I.  Abnormalities  of  growth  and  arrests  in  development. 
II.  Changes  in  form  and  in  position. 

III.  Inflammations  and  disturbances  in  nutrition. 

IV.  Injuries. 

V.  New  growths. 
VI.  Gynaeological  operations  and  procedures. 

280 


PROPHYLAXIS  IN  THE  DISEASES  OF  WOMEN 

In  each  chapter  will  be  set  forth  in  order  the  preventive 
treatment  of — 

(a)  The  primary  cause  or  predisposition  to  the  disease. 
(&)  The  exciting  cause. 

(c)  The  sequelse,  including  complications  arising  out  of 
pregnancy. 

(d)  The  results  of  typical  errors  in  the  treatment  of  the 
disease. 


I.    Abnormalities  of  Formation  and  Arrests 
in  Development 

In  so  far  as  the  defects  in  development  are  congenital, 
their  aetiology  lies  in  the  yet  obscure  region  of  general 
teratology,  and  of  this  we  only  know  that  it  includes 
several  utterly  different  causes.  In  the  first  place  there 
are  diseased  ova  analogous  to  degenerate  spermatozoa  and 
due  to  poisoning  by  lead,  mercury,  alcohol  and  morphine. 
Further  diseased  conditions  of  the  decidua,  primary  or 
secondary,  may  at  the  same  time  give  rise  to  disease  in  the 
foetus  and  produce  abnormalities  in  growth  or  inflammatory 
adhesions.  Congenital  malformations  may  also  be  caused 
by  general  as  well  as  by  local  infective  disorders  such  as 
influenza,  tuberculosis,  syphilis,  and  gonorrhoea.  Disturb- 
ances in  nutrition  are  probably  also  produced  by  the  toxins 
of  these  diseases,  by  pyrexia  and  by  obstruction  to  the 
circulation,  as  in  disappearance  of  the  liquor  amnii  in  the 
first  six  months  and  adhesions  between  the  embryo  and  the 
membranes,  and  subchorionic  haematomata.  The  more 
chronic  these  influences  and  the  longer  they  have  been  at 
work,  the  more  likely  is  it  that  the  child  will  live  but  will 
be  deformed.  But  under  what  special  circumstances  these 
causes  act  upon  the  embryo  so  as  to  produce  deformity  is 
still  entirely  beyond  our  knowledge. 

In  the  female  generative  organs  deformities  are  very 
often  met  with ;  on  the  whole  malformations  are  most 
frequent.  The  abnormalities  of  the  uterus  and  of  the 
Fallopian  tubes  in  children  who  are  otherwise  healthy  must 

281 


THE  PEEVENTION  OF  DISEASE 

arise  from  a  simple  arrest  in  development  of  both,  or  of 
one  of  the  ducts  of  Miiller,  and  thus  are  produced  the 
uterus  bicornis  and  unicornis.  Here  preventive  treatment 
is  limited,  and  it  can  only  be  suggested  that  mothers  and 
those  who  will  become  mothers  should  be  healthy,  and 
especially  that  all  chronic  disorders  of  the  sexual  organs 
should  be  treated.  The  same  holds  good  for  the  father. 
Those  who  have  tuberculous  disease  of  the  genital  organs 
should  not  marry. 

But  far  more  important  to  the  physician  is  the  preven- 
tive treatment  in  cases  where  congenital  malformations 
already  exist.  And  this  will  depend  upon  the  period  of 
life  reached :  at  birth,  at  puberty,  before  marriage,  after 
marriage,  during  the  first  pregnancy,  during  labour,  and 
with  regard  to  the  question  of  subsequent  pregnancies. 

1.  In  complete  absence  of  uterus  and  vagina  it  is  generally 
advisable  not  to  marry  ;  so  too  when  there  is  a  rudimentary 
vagina,  because  coitus  will  increase  the  molimina  menstru- 
alia  if  the  ovaries  are  present.  The  continuance  of 
menstruation  may  be  prevented  by  removal  of  the  ovaries. 
Unhappiness  in  marriage  may  result  from  the  incapacity 
to  fulfil  the  physical  functions,  and  in  such  cases  the 
construction  of  a  vagina-like  cul-de-sac  is  followed  with 
partial  success. 

2.  In  atresia  vaginae  with  a  well  formed  uterus  and 
ovaries,  a  vaginal  passage  should  be  made.  The  same  holds 
good  for  diaphragmatic  or  cord-like  atresia  of  the  cervix, 
vagina,  hymen,  or  vulva  ;  and  this  should  be  done  partly  to 
prevent  sterility  and  partly  to  prevent  the  difficulties 
connected  with  menstruation  and  with  childbirth. 

3.  In  cases  of  pseiido-heriifiaphrodism  an  attempt  to  deter- 
mine the  sex  should  I'be  made,  but  this  is  often  not  possible 
till  puberty  with  its;  well  marked  sexual  inclinations.  "We 
may  be  guided  by\  the  knowledge  that  most  pseudo- 
hermaphrodites havei  been,  proved  to  be  males,  and  several 
of  them  have  been  capable  of  procreating,  and  this  is  the 
more  likely  to  be  the  case  the  better  the  genital  protuber- 
ance is  developed  afid  when  the  catheter  shows  that  a 
cul-de-sac  exists  in  jbhe  posterior  wall  of  the  urethra.     In 

282 


PROPHYLAXIS   IN  THE  DISEASES   OP  WOMEN 

female   pseiiclo-liermaplirodites    atresia    of    the   vagina    is 
always  found. 

4.  Congenital  recto-vaginal  or  recto- vulval  fistulae  should 
be  treated  early  so  that,  apart  from  the  considerations  of 
cleanliness,  no  infection  of  the  genital  canal  from  this 
source  shall  arise  during  childbirth. 

5.  Of  more  frequent  practical  importance  is  the  preventive 
treatment  in  cases  of  uterus  unicornis  and  bicornis  and 
septa  in  the  vagina  and  uterus,  considered  in  relation  to 
generative  processes. 

If  in  weakly  individuals  amenorrhoea  exists  as  a  compli- 
cation of  this  malformation,  marriage  should  be  avoided  ; 
conception  very  rarely  occurs.  In  the  married,  septa  should 
be  divided  to  prevent  difficulties  in  childbirth.  Such  may 
arise  too  from  a  hymen  stretched  tensely  across  the  orifice. 
If  conception  has  taken  place,  we  must  act  according  to  the 
rules  given  in  the  section  on  Obstetrics. 

6.  In  regard  to  the  presence  of  a  third  ovary,  it  must  be 
mentioned  that  if  oophorectomy  is  undertaken  as  preventive 
treatment  for  menorrhagia  from  a  fibroid  or  other  cause, 
the  possibility  of  a  third  ovary  must  be  borne  in  mind  so 
that  no  failure  may  result. 

Far  more  successful  are  the  measures  which  preventive 
treatment  can  bring  to  bear  upon  the  abnormalities  of 
formation  during  childhood  and  at  puberty. 

Preventive  treatment  in  the  infantile  condition  of  the 
genital  organs  should  aim,  before  marriage,  at  improve- 
ment of  the  entire  general  constitution ;  local  treatment 
should  generally  be  resorted  to  only  after  marriage.  The 
general  treatment  should  not  be  restricted  to  combating 
the  chlorosis  and  anaemia,  or  to  allaying  a  chronic  dyspepsia, 
but  should  embrace  a  regime  which  will  raise  the  tone  of 
and  strengthen  the  entire  physical  and  mental  life. 
Hysteria  and  neurasthenia,  dyspepsia  and  chlorosis  should 
be  overcome  by  a  well  regulated  mode  of  life,  regular  and 
not  too  fatiguing  work,  eight  to  ten  hours  of  sleep  and 
early  retiring  to  bed,  five  meals  a  day  of  easily  digested 
food,  moderate  exercise  calculated  to  strengthen  the  muscles, 
every  morning  bathing  with  cool  water  of  80°  F.,  70°  F., 

283 


THE  PREVENTION  OF  DISEASE 

or  65°  F,,  according  to  the  state  of  nutrition,  the  avoidance 
of  mental  exertion  and  of  amusements  which  excite  the 
imagination  and  burden  the  memory.  In  place  of  these, 
the  wholesome  mental  influence  of  a  simple  family  and 
home  life,  the  avoidance  of  all  wine,  beer,  tea,  coffee  and 
spices,  while  chocolate  and  sweetmeats  should  only  be 
allowed  exceptionally  as  dainties.  The  choice  of  recreations 
and  amusements  should  be  restricted  to  simple  ones  which 
do  not  excite  the  senses  and  the  imagination,  while  the 
desire  for  work  and  the  sense  of  duty  and  training  in  self 
control  should  be  aroused — in  short,  the  causes  of  effemin- 
acy, of  eccentricity,  and  of  hysterical  attacks  should  be 
removed.  In  general  such  patients  are  deficient  in  bodily 
heat,  and  therefore  it  is  a  mistake  to  use  strong  measures 
to  try  and  fortify  them  against  cold,  or  to  dress  young 
and  delicate  children  in  clothing  insufHciently  warm. 

Hydropathy  may  be  of  value  if  we  select  applications 
which  are  not  too  stimulating.  So  too  general  and  special 
massage  of  the  abdomen  and  the  thighs.  In  the  summer 
at  least  six  weeks  stay  in  the  country,  or  better  at  the 
seaside,  or  at  some  elevated  district  with  pine  forests. 
Along  with  this  drugs  should  be  given.  Firstly  those 
containing  iron,  such  as  haemalbumin,  pilula  ferri,  ferratin, 
liquor  ferri  manganatis  saccharatus,  haemol  and  haemo- 
gallol,  Blaud's  pill,  and  per  rectum  alkarnose  is  the  best 
form.  Then  stomachics  and  tonics  such  as  tinctura  cin- 
chonae,  nutrol,  chloralbacrd,  acidum  hydrochloricum  dilutum 
and  liquor  arsenicalis.  For  very  neurotic  anaemic  girls  the 
Weir-Mitchell  and  Playfair  treatment  is  suitable.  Special 
treatment  is  needed  for  certain  definite  symptoms  such  as 
dysmenorrhoea,  scanty  menstruation  and  amenorrhoea,  or 
menorrhagia  with  anaemia.  It  is  a  question  essentially  of 
regulation  of  the  blood  supply,  and  can  be  accomplished  by 
the  general  measures  before  mentioned,  be  the  case  one  of 
scanty  menstrual  flow  or  of  menorrhagia.  As  additional 
treatment  for  delayed  or  scanty  menstruation  must  be  men- 
tioned foot  baths  hefore  the  cessation  of  the  period.  The 
footbath  may  be  ordinary  hot  footbaths  reaching  to  above 
the  ankles,  or  a  footbath  in  which  the  feet  are  immersed 

284 


PROPHYLAXIS   IN  THE   DISEASES   OF  WOMEN 

alternately  in  water  of  65°  F.  and  of  104°  F.,  with  or  with- 
out the  addition  of  salt  or  mustard  ;  then  massage  or  water 
compresses  on  the  lower  extremities  and  abdomen,  warm 
hip  baths  and  warm  full  baths,  and  mustard  leaves  upon 
the  inner  surface  of  the  thighs.  For  dysmenorrhoea  the 
same  line  of  treatment  is  required  with  hot  fomentations 
and  enemata.  For  habitual  menorrhagia  the  treatment 
before  the  period  should  comprise  a  cold  water  compress  on 
the  abdomen  and  mustard  leaves  over  the  hepatic  region, 
and  during  the  intermenstrual  period  the  above  mentioned 
general  treatment. 

Remedies  in  addition  to  iron  and  tonics  which  act  well 
in  all  these  cases  by  regulating  the  blood  supply  are 
ergotin,  stypticin,  which  is  also  a  sedative,  and  especially 
in  cases  of  menorrhagia  the  fluid  extract  of  hydrastis 
given  several  days  before  the  expected  period.  The  same 
result  may  be  quickly  and  effectually  attained  by  a  pro- 
longed use  of  calcium  hypophosphite  or  of  sodium  iodide 
in  increasing  doses,  or  the  rectal  or  subcutaneous  injection 
of  a  2  per  cent,  gelatin  emulsion,  or  a  3  per  cent,  solution 
of  sugar. 

In  the  married,  local  preventive  treatment  is  more 
important  and  may  be  recommended  without  hesitation  : 
hot  vaginal  douches  of  salt  and  water  or  of  infusions  or 
mucilaginous  sedatives,  the  patient  being  in  the  dorsal 
position.  For  dysmenorrhoea  with  scanty  menstrual  flow, 
dilatation  and  stretching  of  the  cervix  by  plugging  or  by 
tents,  several  times  and  always  at  least  one  week  before  the 
menstrual  period,  with  strict  asepsis  and  with  after  treat- 
ment according  to  the  directions  already  given. 

I  have  repeatedly  seen  sterility  quickly  cured  by  this 
treatment ;  with  the  cessation  of  dysmenorrhoea,  the 
vaginismus  simultaneously  disappears. 

Menorrhagia  and  the  tendency  to  early  miscarriage, 
which  is  apparently  combined  with  this  condition,  may  be 
cured  by  curetting,  after  dilatation  of  the  cervix,  if  the 
disease  has  already  existed  a  long  time,  or  by  the  internal 
application  of  steam  (atmocausis).  If  all  other  methods 
have  failed,  the  latter  may  be  used  in  the  unmarried  also 

285 


THE  PREVENTION   OE  DISEASE 

■for  severe  and  otherwise  incurable  dysmenorrlioea,  the 
cervical  canal  should  be  suflficiently  dilated  and  protected 
from  the  hot  tube  by  some  material  which  is  a  bad  con- 
ductor of  heat,  such  as  gauze ;  the  temperature  must  not  be 
higher  than  105°  C.  (220°  F.)  and  the  steaming  must  not 
exceed  a  quarter  of  a  minute. 

By  these  hot  vaginal  irrigations  and  by  the  use  of 
tampons  to  produce  dilatation  an  increased  flow  of  blood 
is  first  of  all  established,  whereby  the  organ  is  increased  in 
size,  as  can  be  shown  by  palpation,  and  its  form  and  con- 
sistence become  more  normal,  the  sharp  angle  of  flexion 
which  otherwise  would  gradually  become  firm  and  hard 
disappears,  the  body  of  the  uterus  comes  to  lie  more  in  a 
line  with  the  cervix,  the  wall  of  the  cervix  becomes  softer 
and  the  os  uteri  remains  wider.  In  this  way  several  factors 
which  tend  to  sterility  are  removed,  and  the  endometrium 
doubtless  undergoes  changes  since  its  functions  are  im- 
proved.    Direct  experiments  to  prove  this  are  wanting. 

It  must  be  briefly  stated  that  preventive  treatment 
against  sterility  should  extend  to  the  male  and  should  be 
directed,  on  the  one  hand,  against  neurasthenic  conditions, 
and,  on  the  other  hand,  against  malformations  of  the  penis 
such  as  epispadias  and  hypospadias,  and  inflammatory  or 
traumatic  strictures  and  prostatic  enlargements. 

II.   Changes  in  the  Form  and  Position  of  the 
Generative  Organs 

It  is  desirable  here  to  distinguish  four  groups ;  symptoms 
connected  with  the  uterus  are  generally  the  most  promi- 
nent, as  the  uterus  forms  the  largest  part  of  the  generative 
organs. 

1.  Herniae.  2.  Descent  or  prolapse,  3.  Inversion  of  the 
uterus.  4.  Pathological  malpositions,  versions  and  flexions 
of  the  uterus.  The  pathological  malpositions  are  displace- 
ments forwards,  backwards  or  to  either  side  of  a  uterus 
which  is  normal  in  form  and  in  its  inclination  to  the  pelvic 
axis ;  whereas  in  "  versions  "  the  uterine  axis  is  inclined  to  the 

286 


PROPHYLAXIS  IN  THE   DISEASES   OF  WOMEN 

pelvic  axis  at  an  abnormal  angle,  generally  backwards  ; 
and  in  "flexions"  an  abnormal  angle  of  flexion  exists 
between  the  body  of  the  uterus  and  the  cervix,  thus  the 
relation  between  the  component  parts  of  the  uterus  is 
changed. 

1.  PREVENTIVE  TREATMENT  IN  HERNIAE 

is  that  of  herniae  in  general,  especially  the  avoidance  of 
everything  that  will  permanently  weaken  the  abdominal 
walls  and  tend  to  increase  the  intra-abdominal  pressure. 

For  our  purpose  we  must  keep  separate  three  groups ; 
{a)  in  which  parts  of  the  generative  organs  form  the  hernial 
contents,  for  instance  a  horn  of  a  uterus  bicornis  or  a  uterine 
appendage  in  an  inguinal  hernia  ;  (&)  in  which  some  part  of 
the  generative  organs  forms  the  hernial  sac,  as  in  ovariocele 
and  enterocele  vaginalis  and  hernia  labialis ;  (c)  repro- 
ductive processes  are  the  exciting  cause  of  a  hernia  in  some 
other  region,  as  in  umbilical,  inguinal  and  femoral  herniae, 
which  are  predisposed  to  by  pregnancy,  or  caused  by  partu- 
rition, or  result  from  the  removal  of  tumours  by  abdominal 
section.  Of  these  group  h  belongs  to  the  inversions  or 
prolapse  of  vagina  ;  and  the  labial  herniae  belong  aetiologic- 
ally  to  group  c.  It  is  rare  to  find  parts  of  the  generative 
organs  as  hernial  contents,  and  in  these  cases  malformations 
generally  play  a  part,  as  in  pseudo-hermaphrodism  and 
uterus  bicornis ;  indeed  the  tendency  to  hernia  may  exist 
from  birth  together  with  a  tendency  to  prolapse  of  the 
uterus  and  vagina  and  rectum.  It  requires  then  only  some 
exciting  cause  to  force  a  passage  through  the  hernial  orifice. 
Such  predisposition  may  be  reduced  by  systematic  moderate 
exercise  of  the  abdominal  muscles,  regular  action  of  the 
bowels  and  urinary  bladder,  and  especially  by  massage  and 
suitable  gymnastic  exercises. 

In  some  cases  the  complete  formation  of  the  hernia  will 
lead  to  troublesome  and  dangerous  consequences,  as  when 
an  abnormally  short  round  ligament  draws  the  ovary  or 
uterine  cornu  into  the  hernial  orifice.  The  menstrual 
troubles  may  then  become  unendurable ;  and  when  impreg- 

287 


THE  PREA^ENTION  OF  DISEASE 

nation  has  taken  place  the  ovum  may  become  lodged  in  the 
hernial  sac  or  the  herniated  uterine  cornu,  instances  of 
both  of  which  have  been  seen  by  the  author.  This  may  be 
prevented  by  timely  closure  of  the  hernial  orifice,  generally 
an  inguinal  one,  with  or  without  removal  of  the  hernial 
contents.  If  some  freely  movable  part  is  concerned,  reduc- 
tion of  the  hernia  must  be  followed  by  use  of  a  truss  to 
prevent  the  troubles  and  dangers  mentioned  above. 

As  every  increase  of  intra-abdominal  pressure  predisposes 
to  hernia,  so  especially  will  pregnancy  and  tumours  of  the 
ovary  or  uterus.  Pregnancy  predisposes  chiefly  by  frequent 
recurrence  or  by  the  presence  of  hydramnion  or  of  twins, 
when  there  exists  some  corresponding  predisposition  or  when 
prophylactic  treatment  has  been  neglected.  This  prophy- 
lactic treatment  consists  of  suitable  exercises  of  the  abdom- 
inal muscles,  support  of  the  abdomen  by  a  suitable  belt 
or  bandage  when  the  uterus  or  tumour  approaches  the 
umbilicus,  or  the  removal  of  the  tumour  before  this. 

Preventive  treatment  is  most  important  during  the 
puerperal  period :  a  uniform  compression  of  the  abdomen 
by  a  bandage  which  may  be  aided  by  pressure  by  a  weight, 
but  the  weight  pressure  must  never  be  employed  alone,  as 
one  so  often  sees,  because  the  intestines  are  thereby  forced 
to  the  sides  and  the  abdomen  is  pressed  flat.  A  gentle 
aperient  may  be  given  on  the  third  day,  and  if  the  abdo- 
minal wall  is  flaccid,  and  disease  of  the  generative  organs 
can  be  excluded,  massage  of  the  abdomen  may  be  performed, 
not  only  to  stimulate  the  action  of  the  intestines  and  the 
circulation  of  the  blood,  but  also  to  raise  the  muscular  tone 
of  the  abdominal  wall  and  reflexly  to  increase  the  blood 
flow  to  the  mammary  glands.  Suckling  is  an  important 
regulator  of  the  involution  of  the  pelvic  organs  and  of  the 
abdominal  wall ;  it  must  be  emphasized  that  too  little 
patience  is  in  this  matter  generally  evinced  by  the  mother 
and  by  the  nurse,  and  also  by  the  doctors.  Sometimes  it  is 
possible  only  after  several  weeks  to  bring  about  a  regular 
and  sufflcient  milk  supply.  On  the  day  this  was  written 
there  came  to  the  writer  a  woman,  thirty-two  years  of  age, 
who  had  been  delivered  of  her  third  child  by  forceps  seven 

288 


PROPHYLAXIS   IN   THE   DISEASES   OF   WOMEN 

weeks  before,  and  who  at  my  urgent  request — she  was 
engaged  in  business  and  had  not  nursed  her  first  two 
children — had  for  four  weeks  perseveringly  tried  to  increase 
the  flow  of  milk,  and  in  consequence  the  milk  had  increased 
to  a  sufficient  quantity.  But  usuall}^  the  attempt  is  given 
up  after  a  few  days,  through  impatience.  In  addition  to 
abdominal  ma,ssage,  somatose  and  plasmon,  which  consist 
of  the  proteids  of  milk,  may  be  recommended  for  this  pur- 
pose, though  the  author  has  found  them  useful  in  increasing 
the  flow  of  milk  also. 

For  meteorism  of  the  intestines,  bitters,  oil  of  peppermint 
and  mucilaginous  or  peppermint  enemata  are  of  service. 

If  the  hernial  orifice  is  already  large,  it  is  desirable 
immediately  after  delivery  to  apply  a  truss,  and  for  this 
purpose  the  English  truss  is  better  than  the  G-erman  one, 
even  during  pregnancy.  During  pregnancy  the  uterus 
usually  impedes  the  passage  for  the  intestine,  even  though 
the  hernial  canal  is  dilated ;  in  the  puerperal  period,  on 
the  other  hand,  the  wide  opening  is  suddenly  uncovered  and 
exposed  to  the  full  abdominal  pressure.  Confinement  to 
bed  for  too  long  during  the  puerperium  is  as  injurious  to 
the  patient  as  getting  up  too  early,  because  the  muscles 
become  relaxed ;  on  an  average  ten  to  twelve  days  is  most 
suitable.  Heavy  lifting  and  hard  work  should  be  alto- 
gether forbidden,  and  systematic  exercise  of  the  abdominal 
muscles  must  be  recommended.  Very  thin  patients  should 
be  fed  to  develop  a  thicker  panniculus  adiposus. 

The  same  holds  good  for  the  care  of  the  abdominal  wall 
before  and  after  abdominal  sections.  From  carefully  com- 
piled statistics  obtained  by  examination  of  patients  who 
had  previously  undergone  an  abdominal  section,  Abel  has 
drawn  the  conclusion  that  the  subsequent  formation  of 
herniae  in  such  patients  is  generally  the  fault  of  the  oper- 
ator, and  is  due  to  inexact  sutures,  pressure  necrosis,  sub- 
cutaneous abscesses,  or  the  inclusion  of  fat  lobules  between 
the  wound  surfaces.  While  acknowledging  the  correctness 
of  much  of  Abel's  work,  yet  there  are  cases  which  have 
already  in  them  a  predisposition  to  the  formation  of  herniae, 
and  in  these  deficient  tone  of  the  abdominal  muscles  plays 

289  u 


THE  PREVENTION  OF  DISEASE 

the  chief  part.  Therefore  exercise  of  these  muscles  and 
careful  suturing  must  be  used,  but  too  many  ligatures 
should  not  be  employed. 

2.  THE  PEEYENTIVE  TEEATMENT  OP  PKOLAPSE  OP 
THE  INTEENAL  GENEEATIVE  OEGANS 

Here  too  we  must  distinguish  between  the  preventive 
treatment  of  the  primary  cause  or  predisposition  to  the 
descent,  of  the  exciting  cause,  and  of  the  sequelae. 

With  regard  to  the  primary  cause,  the  prolapse  may  be 
congenital ;  this  is  very  rare.  I  found  one  such  case  in 
the  Munich  Frauenklinik,  in  a  child  with  a  lumbo-sacral 
meningocele ;  a  second  case  I  saw  in  the  Heidelberg  Frau- 
enklinik. In  literature  I  knew  then  of  only  one  case  by 
Qviesling ;  several  others  have  since  been  published,  and 
some  with  spina  bifida  as  in  the  case  mentioned  above. 
The  causal  connexion  which  possibly  exists  between  the 
spina  bifida  and  the  incomplete  prolapse  produced  by  exces- 
sive hypertrophy  of  the  cervix  was  first  pointed  out  by 
Winkel ;  in  other  similar  cases  there  is,  as  a  matter  of  fact, 
a  congenital  prolapse  of  the  whole  uterus. 

I  mention  this  aetiological  possibility  here  because  it  is 
not  at  all  improbable  that  disturbances  of  the  central 
nervous  system,  especially  of  the  lumbar  part  of  the  spinal 
cord,  are  the  immediate  cause  of  the  appearance  of  these 
lumbo-sacral  symptoms  in  all  relaxed  conditions — muscular 
as  well  as  vasomotor — of  the  ligamentous  and  fascial  struc- 
tures of  the  pelvis,  of  which  prolapse  of  the  uterus  and 
vagina  represents  the  final  stage.  To  treat  these  specially 
is  beyond  our  knowledge  and  our  skill.  Here  too  we  fall 
back  upon  the  treatment  of  the  general  neurasthenia,  and 
upon  prevention  of  over  stretching  of  the  elastic  liga- 
mentous structures,  and  upon  the  restoration  so  far  as 
possible  of  the  former  elasticity  after  any  severe  stretching. 
This  stretching  may  occur  in  pregnancy,  or  after  the  cervix 
has  been  drawn  down  for  operations,  or  it  may  follow  heavy 
lifting  or  sudden  violent  falls  upon  the  buttocks. 

The  general  neurasthenia  which  here  shows  itself  locally 
as  a  disturbance  in  innervation,  in  the  form  of  diminished 

290 


PROPHYLAXIS   IN  THE  DISEASES   OF   WOMEN 

tone  of  all  tlie  elastic  elements,  including  those  of  the  vessel 
walls,  is  to  be  treated  by  the  measures  already  given  under 
"Infantile  conditions  of  the  Generative  Organs,"  and  under 
"  Herniae,"  for  improving  the  tone  and  vigour  of  the  body. 
By  these  measures  we  remove  too  the  symptoms  which  are 
in  part  concomitant,  in  part  reflex. 

The  knowledge  that  a  relaxed  condition  of  the  pelvic 
floor  allows  of  the  completion  of  a  prolapse  which  had 
commenced  through  the  yielding  of  the  ligaments  and  of 
the  subserous  parietal  pelvic  tissues,  suggested  the  idea  of 
using  gynaecological  massage  and  resistance  exercises  to 
raise  the  tone  of  the  pelvic  floor.  The  results  have  unfor- 
tunately not  been  encouraging,  yet  as  adjuncts  these 
methods  need  not  be  despised. 

The  first  result  of  relaxation  of  the  ligaments  is  retro- 
version of  the  uterus  ;  and  this  may  appear  even  in  J^'oung 
girls,  but  most  freqiiently  begins  at  the  first  or  second 
confinement  when  there  is  a  corresponding  predisposition  to 
it.  When  once  the  uterine  axis  comes  to  lie  in  the  same 
direction  as  the  vaginal  axis,  especially  when  there  is  a 
ruptured  perineum  or  the  legs  are  rather  wide  apart  and 
the  body  is  bent  forward — then  a  sudden  increase  of 
abdominal  pressure,  as  in  heavy  lifting  or  a  sudden  violent 
fall,  suffices  to  bring  the  uterus  to  the  vulva,  giving  rise  to 
acute  prolapse.  In  the  posture  described,  the  musculature 
of  the  perineum  together  with  its  fasciae  is  relaxed.  If 
then  the  physician  discovers  a  retroversion  of  the  uterus  or 
a  defective  perineum,  he  should  prescribe  suitable  pre- 
cautionary measures  and  advise  immediate  plastic  repair  of 
the  perineum. 

Retroversion  brings  with  it,  not  only  the  risk  of  prolapse 
of  the  uterus,  but  is  indeed  the  first  stage  to  it  ;  in  most 
cases  however  this  fortunately  leads  only  to  a  slight  degree 
of  descent  so  long  as  the  functions  of  the  pelvic  floor  are 
normal.  It  may  be  suddenly  lost  by  too  early  and  severe 
abdominal  pressure  in  labour,  or  by  too  long  continued 
impaction  of  the  head,  or  by  too  sudden  stretching  by  lever- 
age and  traction  with  forceps.  If  the  head  has  only  jus- 
passed  the  OS  and  the  perineum  is  still  undilated  and  extract 

291 


THE  PREVENTION  OF  DISEASE 

tion  is  indicated,  it  is  best  first  to  introduce  a  large-sized 
dilatable  indiarubber  bag,  or  if  there  is  not  time  enongb 
for  this — and  it  takes  some  minutes — then  make  a  deep 
lateral  perineal  incision  through  the  sphincter  vaginae  and 
levator  ani  of  one  side,  and  immediately  after  delivery  bring 
together  the  edges  of  this  incision  after  careful  cleansing 
by  deep  catgut  sutures. 

The  most  appropriate  time  for  preventive  treatment  of 
retroversion  and  of  descent  of  the  uterus  is  during  the 
puerperium,  because  on  the  one  hand  at  this  time  the 
foundation  for  subinvolution  of  the  uterus  and  ligaments  is 
most  frequently  laid,  and  on  the  other  hand  the  genitalia 
are  most  plastic  at  this  time  and  can,  as  it  were,  be  better 
moulded  by  suitable  treatment.  We  must  remember  that 
it  is  by  no  means  most  common  for  these  processes  of 
descent  to  start  from  the  uterus,  but  rather  that  the  first 
stage  of  it  belongs  to  the  vagina.  Descent  of  the  anterior 
vaginal  wall  is  the  most  frequent ;  and  is  followed  by 
descent  of  the  adjacent  part  of  the  bladder,  and  the  uterus 
is  then  drawn  down.  Prolapse  of  the  vagina  thus  leads  to 
cystocele ;  and  prolapse  of  the  posterior  vaginal  wall  to 
rectocele.  Prolapse  of  the  posterior  wall  may  bring  about 
a  prolapse  of  the  organs  contained  in  the  pouch  of  Douglas, 
and  may  give  rise  to  serious  obstetric  complications,  and 
these  should  therefore  be  replaced  beforehand  or  removed. 

All  these  processes  of  descent  may  easily  be  prevented 
during  the  puerperal  period  by  the  use  of  pessaries.  These 
should  be  introduced  at  the  end  of  the  first  week  with  the 
strictest  aseptic  precautions.  Broad  rimmed  smooth 
celluloid  or  vulcanite  pessaries  should  be  used,  never  porous 
elastic  indiarubber  rings,  which  might  injure  the  delicate 
hyperaemic  mucus  membrane  or  by  absorption  of  lochial 
discharge  become  a  nidus  for  bacteria.  The  shape  should 
be  oval,  and  slightly  concave  towards  the  symphysis ;  or 
when  there  is  a  tendency  to  retroflexion,  the  S  shaped  or 
Hodge  pessary  with  a  very  broad  bar  for  the  posterior 
vaginal  vault  may  be  employed. 

In  such  cases  the  perineum  often  sinks  down  and  the 
vagina  threatens  to  prolapse  ;    they  should  then  be  sup- 

292 


PROPHYLAXIS   IN  THE   DISEASES   OF  WOMEN 

ported  during  involution  by  a  T  bandage,  firmly  applied. 
When  a  tendency  to  retroversion  of  the  uterus  is  known  to 
exist,  the  patient  should  be  kept  in  the  lateral  position  as 
much  as  possible  during  the  j)uerperium.  Too  early  getting 
up,  that  is  before  the  fourteenth  day,  or  too  long  a  confine- 
ment to  bed,  that  is  after  the  third  week,  and  too  early 
hard  work  and  heavy  lifting  should  be  forbidden. 

The  patient  should  be  seen  once  a  week  till  the  next 
menstruation,  so  that  as  the  involution  of  the  vagina  pro- 
ceeds smaller  pessaries  may  be  substituted.  The  round 
Meyer  ring  pessaries  are  of  no  use  because  of  their  form, 
since,  according  to  my  observations,  they  produce  eversion  of 
the  lips  of  the  os  of  the  soft  puerperal  uterus  ;  then  the 
cervix  sinks  into  the  ring,  and  there  arises  a  dragging  on 
the  cervico- vaginal  muscular  fibres,  which  pass  on  the  one 
hand  to  the  vaginal  wall,  and  on  the  other  hand  radiate 
fan-like  into  the  lips  of  the  os  uteri ;  and  hence  the 
eversion  occurs.  There  are  no  purely  circular  or  oblique 
muscle  fibres  to  offer  a  more  effective  resistance  than  the 
elastic  fibres  are  able  to  do.  "We  must  therefore  not  only 
with  the  puerperal  uterus  but  with  every  relaxed  uterus, 
especially  when  there  exists  lateral  laceration  of  the  os,  be 
very  cautious  in  the  use  of  perfectly  circular  and  thick 
brimmed  pessaries  with  small  lumen ;  oval  pessaries  are 
better.  The  most  rational  treatment  is  a  fixation  opera- 
tion and  a  perineorraphy. 

The  vasomotor  tone  may  be  improved  by  the  administra- 
tion of  ergot  and  by  hot  vaginal  douches  several  times 
daily,  or  by  irrigations  with  cold  and  hot  water  alternately 
(60°  to  70°  F.  and  108°  to  115°  F.).  Gynaecological  mas- 
sage acts  quickly,  but  cannot  be  used  till  after  the  lying-in 
period.  The  combination  of  pressure  and  heat  by  a  vaginal 
"thermophore"  is  useful;  the  temperature  of  the  sodium 
acetate  contained  in  it  reamins  constant  for  hours. 

Prolapse  of  the  vagina  wall  alone  occurring  after  labour 
is  not  seldom  combined  with  incontinence  of  urine,  and  is 
most  successfully  treated  so  as  to  prevent  further  prolapse 
by  astringent  tampons,  such  as  glycerine  of  tannic  acid  or 
a   ten   per  cent,  solution  of  aluminium  acetate.     A  third 

293 


THE  PREVENTION  OF  DISEASE 

preventive  measure  in  the  piierperium  is  the  suturing  of  a 
rupture  of  the  perineum  directly  after  the  third  stage  of 
labour.  The  sooner  and  the  more  exactly  the  sutures  are 
inserted,  the  more  likely  is  primary  union  to  occur.  The 
surfaces  should  be  properly  fitted  one  to  the  other ;  this  is 
especially  important  in  the  frequent  lateral  tears.  The 
vaginal  rent  must  be  sutured  in  its  whole  length,  otherwise 
the  healing  of  the  perineal  wound  may  be  prevented  by 
the  penetration  of  lochial  discharge.  The  deep  catgut 
sutures  must  pass  deeply  below  the  wound,  but  they  should 
be  only  few  in  number  so  that  there  may  not  be  too  much 
material  to  be  absorbed.  The  points  of  entry  and  of  exit  of 
the  stitches  should  lie  near  the  edge  of  the  wound,  but  the 
needle  should  pass  far  into  the  neighbouring  tissues. 

The  after-treatment  must  not  be  too  active.  The. wound 
should  be  sprinkled  with  an  antiseptic  jDOwdei — I  prefer 
airol  or  nosophen — or  some  airol  paste,  which  softens  on  the 
skin,  should  be  carefully  applied.  With  due  cleanliness 
and  when  the  lochia  are  normal,  catgut  or  silk  is  as  good  a 
material  for  sutures  as  celluloid  thread,  silkworm  gut  or 
silver  wire.  Non-absorbable  sutures  should  be  removed  at 
the  end  of  the  first  week. 

If  primary  union  fail,  or  the  physician  is  not  called  to 
the  patient  till  the  second  or  third  day,  it  is  advisable  to 
wait,  and  the  plastic  perineal  operation  should  be  under- 
taken six  or  eight  weeks  after  the  confinement.  Secondary 
suturing  of  the  granulating  surfaces  after  paring  is 
generally  more  or  less  unsuccessful.  Sometimes  a  small 
abscess  may  then  form,  which  in  favourable  cases  opens  at  a 
spot  between  the  vaginal  and  perineal  sutures,  but  which, 
should  it  become  larger,  may  cause  troublesome  fistulae 
(recto- vaginal  or  perineo- vaginal). 

Long  continued  infective  inflammations  and  frequently 
recurring  pregnancies  bring  about  conditions  in  weakly 
patients  exactly  similar  to  those  caiised  by  puerperal  sub- 
involution :  immediately  after  normal  childbirth  the  anterior 
lip  of  the  OS  uteri  may  be  felt  immediately  within  the 
vagina.  Through  long  continued  infective  inflammations 
the  vessel  walls  gradually  lose  their  tone  ;  this  occurs  both 

294 


PROPHYLAXIS  IN   THE   DISEASES   OP   AVOMEN 

in  the  uterus  wliicli  has  been  thickened  by  metritis  and  in 
the  ligaments.  It  occurs  also  in  the  vagina  in  which  there 
is  chronic  hyperaemia.  The  prevention  or  early  cure  of  all 
infective  inflammations  of  the  vagina,  of  endometritis,  of 
erosions  and  of  eversion,  is  a  cardinal  point  in  the  preven- 
tion of  prolapse. 

In  a  similar  manner  by  muscular  and  vasomotor  dis- 
turbances in  innervation  perverted  sexual  habits  (mastur- 
bation and  onanism)  will  tend  to  cause  retroversion  and 
descent  of  the  uterus.  Here  also  the  appearance  of  the 
injurious  reaction  which  follows  frequent  congestion  is 
dependent  upon  the  state  of  the  general  neurotic  condition 
of  the  individual.  Finally,  we  recognize  a  purely  mechanical 
displacement  of  the  uterus  either  upwards  or  downwards  by 
tumours.  The  simple  downward  displacement  of  a  uterus 
may  lead  to  total  prolapse,  if  at  the  same  time  it  becomes 
retroflexed  and  gravid,  and  in  enlarging  has  become  incar- 
cerated below  the  promontory.  In  both  cases  it  should  be 
replaced  ;  either  the  uterus  or  the  tumour  should  be  pushed 
upwards  and  forwards  out  of  the  pelvis,  and  a  pessary 
inserted.  If  there  are  peritoneal  adhesions  which  make 
replacement  impossible,  then  all  preventive  measures  are 
in  vain  and  radical  treatment  should  be  resorted  to. 

In  the  last  sentences  we  have  already  passed  over  to  the 
preventive  treatment  of  the  sequelae  of  prolapse.  Simple 
descent  of  the  uterus  predisposes  to  miscarriage  when  the 
walls  are  relaxed  or  the  os  is  everted.  It  can  be  prevented 
by  immediate  insertion  of  an  oval  pessary  which  should  be 
worn  to  the  fifth  month  of  pregnancy.  Plastic  operations 
for  the  eversion  of  the  os  are  contra-indicated  during 
pregnancy,  because  operations  on  the  cervix  readily  cause 
miscarriage.  But  colporrhaphy  and  perineal  operations 
may  be  carried  out.  After  such  an  operation  at  the  sixth 
month  I  have  observed  slight  labour  pains  for  a  few  days, 
but  then  all  went  well.  The  parts  become  so  readily 
dilated  again  that  it  is  better  to  postpone  the  operation  till 
after  the  puerperal  period,  or  till  after  lactation. 

The  results  of  a  simple  prolapse  are  apparent  in  all  the 
organs   concerned.       They    are   excoriation   and    catarrhal 

295 


THE  PREVENTION  OE  DISEASE 

inflammation  of  the  mucous  membrane  of  the  vagina,  erosion 
and  eversion  of  the  li]3S  of  the  os  uteri,  oedema  and  gradual 
hypertrophy  of  the  cervix,  the  formation  of  pouches  in  the 
bladder  and  rectum  with  catarrh  through  stagnation  of 
the  urine  and  faeces,  the  formation  of  calculi,  circulatory 
disturbances,  as  in  the  formation  of  haemorrhoids,  even 
gangrene  of  the  prolapsed  parts,  kinking  of  the  urethra 
and  ureters  with  secondary  hydronephrosis,  entero-kolpo- 
cele,  and  peritoneal  adhesions  of  the  uterus  to  the  organs  in 
Douglas'  pouch  which  has  also  descended — and  as  a  conse- 
quence sterility.  All  these  troubles,  some  of  them  very 
serious,  may  be  prevented  by  early  radical  cure  of  the 
prolapse.  The  commencing  formation  of  adhesions  should 
be  met  by  replacement  of  the  uterus.  If  firmer  adhesions 
are  present,  they  are  stretched  or  broken  down  by  massage 
and  subsequent  plugging  of  the  posterior  cul-de-sac. 
Lastly,  a  few  words  about  the  harmful  results  of  unsuitable 
treatment  of  prolapse.  Concerning  the  use  of  pessaries, 
I  would  refer  to  what  has  been  said  above  about  the  action 
which  round  thick-brimmed  rings  exercise  in  producing 
eversion  when  the  uterus  is  relaxed.  The  lumen  of  the 
pessary  must  be  wide  enough  to  allow  the  vaginal  part  of 
the  cervix  to  lie  easily  within  it,  otherwise  strangulation 
of  the  cervix  and  pressure  ulcers  will  occur.  To  avoid 
excoriations  and  ulcerations  of  the  vaginal  mucous  mem- 
brane the  instrument  should  be  removed  for  a  few  days 
every  three  months,  or  after  the  climacteric  even  oftener. 
Ulceration  may  lead  to  incrustation  of  the  pessary,  and  to 
the  formation  of  granulations  and  even  to  fistulae.  For 
washing  out  the  vagina  it  is  best  to  use  lukewarm  normal 
saline  solution,  and  this  should  be  done  in  the  recumbent 
posture,  daily  if  there  is  leucorrhoea,  otherwise  once  a  week 
or  at  least  several  times  after  every  period.  As  soon  as  the 
discharge  becomes  irritating  or  foetid,  the  pessary  must  be 
removed  and  the  vagina  irrigated  with  a  weak  solution  of 
potassium  permanganate. 

The  pessary  must  not  tensely  stretch  the  vaginal  walls, 
and  the  lower  bar  must  not  lie  so  as  to  be  visible  at  the 
vulva  ;  pain,  a  sensation  of  great  pressure,  incontinence  or 

296 


PROPHYLAXIS  IN  THE  DISEASES   OP   WOMEN 

retention  of  urine,  and  catarrh  of  the  vagina  would 
result. 

If  the  vaginal  part  of  the  cervix  is  too  short,  it  slips  out 
of  the  pessary  and  pressure  effects  readily  arise.  In  such 
cases  a  Hodge  S-shaped  pessary  should  be  used,  and  the 
upper  bar  should  be  directed  backwards,  to  stretch  the  j^arts 
transversely  and  obliterate  the  folds  of  Douglas'  pouch.  If 
scar  tissue  in  the  vaginal  vault,  left  by  parametritis  or  by 
lacerations,  or  if  too  short  an  anterior  vaginal  wall  prevents 
a  correct  position  of  the  ring,  then  pieces  of  vaginal 
mucous  membrane  must  be  excised  by  oval  incisions,  and 
stitched  parallel  to  the  longer  diameter  of  the  oval,  in  such 
a  way  that  in  place  of  this  shortening  an  increase  in  length 
is  obtained. 

"When  the  ring  is  imperfectly  or  not  at  all  retained  in 
consequence  of  a  defective  perineum,  or  of  too  wide  and  lax 
a  vagina,  a  plastic  operation  should  be  performed.  If 
operation  is  refused,  or  if  the  patient  is  old,  Schultze's 
sledge  pessary  should  be  introduced,  reversed  in  such  a  way 
that  the  anterior  curve  looks  towards  the  posterior  vaginal 
vault  and  the  vaginal  part  of  the  cervix  is  carried  up  by 
that  segment.  When  the  perineum  is  intact,  the  vagina 
very  wide,  and  the  prolapse  constantly  recurs,  E.  Martin's 
modification  of  Zangerle's  stemmed  pessary,  which  rests 
upon  the  levator  ani  muscle,  is  useful.  So  too  is  Hewitt's 
cradle  or  clamp  pessary.  The  old  stemmed  pessary  on  the 
other  hand  is  very  bad,  as  it  causes  troublesome  ulcers. 
As  a  last  resource,  the  oval  hollow  egg-shaped  vulcanite 
pessaries  (generally  No,  2  and  3)  brought  into  use  again  by 
Breisky,  with  a  T  bandage,  are  to  be  recommended ;  these 
must  be  removed  by  forceps  when  they  have  to  be  cleaned. 

When  hypertrophy  of  the  cervix  or  tumours  are  present 
pessaries  must  on  no  account  be  used. 

With  regard  to  hysteropexy  in  women  capable  of  child- 
bearing,  vaginal  fixation  or  vesical  fixation  is  dangerous,  and 
this  is  true  even  if  their  most  recent  modifications  are  used, 
which  are  intended  to  avoid  adhesions  being  formed  too  high 
up  or  too  extensively,  since  their  extent  can  never  be  deter- 
mined beforehand.   For  very  serious  disturbances  have  been 

297 


THE   PEEVENTION   OF  DISEASE 

observed  during  pregnancy  and  childbirth  through  the 
failure  of  the  anterior  uterine  wall  to  expand,  and  the  con- 
sequent overstretching  of  the  posterior  wall ;  and  in  order 
to  render  delivery  possible,  it  has  been  necessary  to  make 
an  incision  through  the  whole  anterior  uterine  wall,  or 
even  perform  a  Caesarian  section.  Similar  disturbances  in 
cases  of  ventrifixation  of  the  fundus  uteri  have  occasionally 
been  reported. 

3.    THE  PREVENTIVE  TREATMENT  OF  INVERSION 
OF  THE  UTERUS 

This  depends  intimately  upon  aetiology.  It  may  be  caused 
by  relaxation  of  the  dilated  cervix  with  very  strong  con- 
tractions of  the  body  of  the  uterus,  and  the  presence  of 
adhesions  between  the  body  which  is  being  expelled  from 
the  uterus  and  the  fundus,  as  in  fibromyoma  or  adherent 
placenta.  It  may  also  be  due  to  relaxation  of  the  body 
of  the  uterus  and  forcible  expression  of  the  placenta  by 
Crede's  method,  or  to  strong  traction  on  the  umbilical  cord  ; 
or  it  may  occur  in  precipitate  labour. 

Fibrous  polypi  should  be  removed  when  they  begin  to 
cause  dilatation  of  the  os  uteri.  When  a  placenta  is  really 
adherent  it  should  be  removed  by  the  hand,  with  strict 
antiseptic  precautions,  Crede's  expression  of  the  placenta 
should  be  made  only  during  a  pain  ;  forcible  traction  should 
never  be  made  on  the  umbilical  cord.  In  threatened  pre- 
cipitate labour  the  patient  should  be  placed  in  the  lateral 
posture  and  forbidden  to  make  any  bearing  down  efforts, 
and  a  sedative  may  be  given. 

Treatment  to  prevent  the  results  which  may  follow 
inversion  consists  essentially  in  immediate  replacement  of 
the  uterus,  for  the  longer  we  wait  the  more  difficult  does  it 
become.  The  best  method  is  to  dilate  the  vagina  and  use 
massage  and  cold  injections,  and  to  administer  ergot  after 
replacement.  A  funnel-shaped  piece  of  peritoneum  is 
carried  down  by  the  inverted  uterus,  and  unless  the  uterus 
is  soon  replaced  peritoneal  adhesions  form  which  later  can 
be  overcome  only  with  difficulty,  if  at  all. 

It   must   be   borne  in  mind   that  an  error  in  diagnosis 

298 


PROPHYLAXIS  IN  THE   DISEASES   OF   WOMEN 

between  au  inverted  uterus  and  a  polypus  has  led  to  the 
removal  of  the  uterus  in  mistake  for  a  polypus. 

During  replacement  counter-pressure  should  be  made  on 
the  abdomen  to  prevent  a  rupture  of  the  vagina. 

4.  THE  PREVENTIVE  TREATMENT  IN  DISPLACEMENTS, 
VERSIONS  AND  FLEXIONS  OF  THE  UTERUS 

These  three  forms,  which  have  been  already  defined,  may 
occur  combined  one  with  another  and  with  change  in  the 
position  in  the  level  of  the  uterus,  as  in  prolapse. 

(a)  With  regard  to  displacements  of  the  uterus,  aetiology 
teaches  that  inflammatory  exudations,  as  in  parametritis 
and  perimetritis,  cause  displacements  in  a  definite  direction  ; 
first  indeed  in  one  direction  by  the  presence  of  the  exudation, 
and  later  in  the  opposite  direction  by  contraction  of  this 
newly  formed  fibrous  tissue  ;  and  this  leads  to  fixation. 
The  same  result  may  follow  appendicitis. 

The  displaced  uterus  generally  remains  movable  when 
the  displacement  is  due  to  a  tumour,  whether  it  be  a  tumour 
of  the  uterus,  of  a  neighbouring  organ,  or  simply  an  habi- 
tually overfilled  bladder  or  rectum,  or  a  hydrosalpinx 
or  pyosalpinx.  A  congenital  inequality  of  the  ligaments  of 
the  uterus  is  unimportant.  Among  tumours  of  the  pouch 
of  Douglas,  extra-uterine  gestation  is  specially  important. 

The  preventive  treatment  to  be  adopted  is  that  described 
under  "  Inflammations  "  and  under  "  Tumours."  Commen- 
cing adhesions  should  be  early  removed  by  massage  to  pre- 
vent an  abnormal  fixation  of  the  uterus. 

During  the  years  of  school  care  should  be  taken  to 
prevent  girls  getting  into  the  harmful  habit  of  neglecting 
to  empty  the  urinary  bladder,  from  mistaken  ideas  of 
propriety.  So  also  with  regard  to  habitual  constipation, 
the  rule  of  a  fixed  hour  for  the  evacuation  of  the  bowels 
from  childhood  onwards  is  the  best  way  of  inducing  regu- 
larity of  the  bowels,  especially  in  chlorotic  girls. 

The  further  development  of  ectopic  gestation  may  be 
prevented  in  the  early  months  by  the  injection  into  the 
tumour  of  small  doses  of  morphine  hydrochloride,  or  it  may 
be  removed. 

299 


THE  PREVENTION   OF  DISEASE 

(6)  By  pathological  auteflexions  of  the  uterus  we  mean 
those  only  which  are  permanent;  they  are  accompanied 
generally  by  very  slight  mobility  of  the  body  of  the  uterus. 

"We  have  already  spoken  of  the  initial  stage  in  the 
anteflexed  infantile  uterus.  The  diminished  mobility 
may  be  the  result  of  the  position  of  the  uterus  in  the 
pelvic  cavity,  or  of  the  relation  of  the  body  to  the  cervix. 
When  the  anteflexion  has  not  been  produced  by  any 
limitation  of  movement  by  fixation,  it  has  been  caused  by 
a  rigidity  of  the  "  flexion  angle,"  as  a  result  of  the  form- 
ation of  inflammatory  fibrous  tissue. 

In  another  variety  the  cause  is  to  be  found  external  to 
the  uterus,  most  frequently  indeed  in  the  cord-like  indura- 
ations  left  by  parametritic  and  perimetritic  exudations. 
These  may  fasten  the  body  of  the  uterus  to  the  bladder  and 
anterior  pelvic  wall  in  front,  or  may  fix  the  cervix  to  the 
posterior  wall  behind — the  latter  being  the  more  frequent. 
If  an  adhesion  draws  back  the  posterior  part  of  the  uterus 
near  the  internal  os,  anteflexion  is  produced.  This  may 
also  be  produced  by  fixation  of  the  cervix  of  the  uterus 
anteriorly,  but  this  is  very  rare. 

Tumours  produce  anteversion  and  anteflexion  in  various 
ways;  as  by  pressure  from  above  and  behind  when  the 
tumour  is  connected  with  some  other  organ,  as  with  an 
ovarian  cyst,  or  by  a  fibroid  in  the  anterior  wall  of  the 
uterus  which  may  simulate  a  flexion  ;  but  the  diagnosis 
can  be  established  by  passing  a  uterine  sound.  Submucous 
polypi  may  also  cause  anteversion.  Fibroids  in  the  anterior 
wall  may,  according  as  they  are  situated  in  the  cervix  or 
in  the  body  of  the  uterus,  produce  either  anteversion  or 
anteflexion. 

Increased  weight  of  the  uterus,  as  in  metritis  or  early 
pregnancy  may  cause  a  bending  forward  and  lowering  of 
the  body  of  the  uterus.  From  what  has  been  said,  it  is 
clear  that  the  preventive  treatment  should  aim  at  the  pre- 
vention or  the  early  cure  of  inflammations  of  the  vagina 
and  uterus,  and  also  of  the  pelvic  connective  tissue,  of  the 
adnexa  and  of  the  pelvic  peritoneum. 

Once  the  acute  inflammatory  stage  has  passed,  it  becomes 

300 


PROPHYLAXIS  IN  THE   DISEASES   OF   WOMEN 

necessary  to  remove  adhesions  by  massage  or  later  by  in- 
cisions to  set  free  the  adherent  organs,  or  by  forcible  break- 
ing down  of  the  adhesions  and  subsequent  plugging  with 
glycerine  gauze.  Compression  by  firm  plugging  of  the 
vagina  with  moistened  cotton  wool  pledgets  or  with  a  shot 
bag  and  the  application  of  bags  of  sand  or  of  shot  to  the 
abdomen  are  useful. 

By  these  measures  too  the  various  sequelae  of  anteflexion 
are  prevented,  such  as  dysmenorrhoea,  sterility,  constipation, 
tenesmus,  and  bladder  troubles.  Whether  removal  of  the 
tumour  is  indicated  depends  upon  its  nature,  and  upon  the 
severity  of  the  symptoms  produced  by  the  anteflexion. 

(c)  The  preventive  treatment  of  retroversion  and  retro- 
flexion of  the  uterus  depends  in  most  cases  upon  the  removal 
of  the  neurotic  disposition,  the  local  effect  of  which  has  been 
to  lower  the  muscular  and  vasomotor  tone  of  the  pelvic 
organs  and  their  ligaments,  and  thus  to  produce  descent  and 
prolapse.  In  speaking  about  the  latter  we  have  already 
enumerated  the  general  and  special  preventive  measures 
to  be  taken,  as  we  believe  retroversion  of  the  uterus  to  be 
the" first  stage  of  descent. 

Congenital  retroversions  are  very  rare  ;  but  the  predis- 
position to  these  may  be  congenital,  and  leads  to  puerile 
retroversion  and  retroflexion  at  puberty,  when  the  body  of 
the  uterus  becomes  heavier  relatively  to  the  cervix.  With 
such  predisposition,  an  habitually  overfilled  urinary  bladder, 
early  excessive  abdominal  straining  and  the  dorsal  position 
in  the  puerperal  period  act  as  exciting  causes  producing 
retroversion  and  later  retroflexion  of  the  uterus.  The 
recognition  of  this  predisposition  affords  the  indication  for 
the  avoidance  of  these  causes.  The  puerperium  is  too 
the  most  favourable  moment  for  the  prevention  or  cure  of 
these  anomalies  in  position,  seeing  that  retroversion  of  the 
uterus  is  produced  by  the  same  causes  which  produce  pro- 
lapse. We  employ  the  same  treatment  for  these  as  for  de- 
scent of  the  uterus.  Here  too  subinvolution  of  the  uterus 
plays  an  important  part,  partly  because  of  the  increased 
strain  upon  the  ligaments,  and  partly  because  of  the  engorge- 
ment of  blood  and  the  consequent  diminution  of  elasticity  of 

301 


THE  PREVENTION  OF  DISEASE 

the  ligaments.  Regarding  the  use  of  pessaries,  I  must  add 
that  the  object  to  be  attained  is  not  the  complete  forward 
replacement  of  the  uterus,  but  rather  the  support  of  the 
posterior  cul-de-sac  and  relief  of  the  strain  on  the  ligaments. 

The  puerperal  processes  however  act  also  in  another  wa}?-, 
the  most  important  of  all :  this  is  by  giving  rise  to  inflam- 
mations, either  alone  or  in  combination  with  injuries  of  the 
vaginal  vault,  and  stretching,  dragging  and  secondary 
relaxation  of  the  generative  organs.  The  inflammation  itself 
next  weakens  the  ligaments.  The  neck  of  the  uterus  may 
be  pulled  forward  by  inflammatory  indurations,  or  the  body 
of  the  uterus  may  be  firmly  fixed  in  Douglas'  pouch  by 
perimetritic  bands.  Apart  from  these  primary  inflammatory 
processes,  secondary  adhesions  may  be  formed  on  the  pos- 
terior surface  of  the  retroverted  uterus.  These  adhesions 
hold  the  uterus  and  thus  make  the  flexion  permanent. 

Just  as  the  weight  of  the  puerperal  or  gravid  uterus  or 
the  enlarged  uterus  in  metritis  may  induce  retroversion, 
and  the  adhesion  between  the  uterus  and  the  intestine  may 
hold  down  a  uterus  which  otherwise  would  be  mobile,  so 
heavy  tumours  may  act  in  the  same  way,  whether  they  are 
situated  in  the  uterus  itself  or  in  the  adnexa  or  in  neigh- 
bouring organs. 

The  preventive  treatment  is  similar  to  that  for  ante- 
flexion of  the  uterus. 

All  troubles  and  morbid  conditions  which  appear  first  in 
later  life  and  cause  chronic  hyperaemia  and  permanent 
laxity  of  the  ligaments  produce  retroversion  of  the  uterus. 

To  this  class  belong  all  chronic  disorders  of  metabolism 
and  dyscrasias,  general  neuropathic  conditions  with  local 
disorders  in  innervation  and  perverted  habits.  Cases  of 
simple  retroversion  also,  in  which  the  author  has  observed 
spasmodic  flexions,  belong  to  this  group.  Preventive  treat- 
ment should  be  directed  against  these  conditions,  according  to 
the  details  already  given  under  "  Infantile  Condition  of  the 
G-enerative  Organs,"  "  Hernise,"  and  "  Prolapse." 

Of  practical  importance  is  the  preventive  treatment  of  the 
sequelae  of  retroversion  and  retroflexion  of  the  uterus,  which 
are  essentially  of  a  nervous  type.     The  controversy  whether 

302 


PEOPHYLAXIS  IN  THE   DISEASES  OF   WOMEN 

these  are  piirely  reflex  or  whether  they  are  accidental  con- 
comitants of  a  hysterical  nature  may  perhaps  be  decided 
by  the  fact,  that  according  to  what  has  been  afore  stated, 
simple  retroversion  and  retroflexion  of  the  uterus  almost 
always  arises  from  a  general  neuropathic  condition,  so  that 
the  requisite  predisposition  for  the  development  of  these 
nervous  reflexes  is  present.  That  such  reflexes  exist  has 
been  proved  as  a  matter  of  fact  by  earlier  observations,  and 
also  by  recent  ones  by  the  author  which  are  free  from 
objections.  For  instance  in  some  cases  a  cough  can  be  caused, 
"  tussis  uterina,"  by  touching  the  posterior  fornix  with  the 
sound  through  a  speculum.  In  the  uterus  itself,  spasmodic 
phenomena  may  be  noticed  by  palpation  if  sufficient  patience 
and  care  are  exercised .  Thus  a  functional  retroflexion  may 
arise  temporarily  from  a  simple  retroversion. 

The  swelling  of  the  mucous  membrane  which  appears  in 
course  of  time  and  finally  causes  chronic  metritis  is  likewise 
the  result  of  a  vasomotor  disorder  of  innervation.  Its  symp- 
toms are  menorrhagia  and  dj'-smenorrhoea ;  the  dysmenor- 
rhoea  is  produced  by  spasmodic  flexion  which  has  been 
already  mentioned,  and  but  seldom  by  any  actual  mechanical 
stenosis  due  to  the  flexion. 

It  is  not  possible  to  look  upon  sterility  as  the  conse- 
quence of  an  ordinary  retroversion  and  retroflexion  of  the 
uterus  without  any  inflammatory  complication  ;  and  apart 
from  complications  the  cause  may  be  found  in  a  lowering  of 
the  general  health  combined  with  a  morbid  condition  of  the 
nervous  sj^stem. 

For  all  these  symptoms  general  treatment  to  raise  the 
tone  of  the  body  is  required.  For  commencing  endometritis 
and  metritis  the  special  treatment  given  under  those 
headings  is  needed.  The  adhesions  described  as  occurring 
between  the  uterus  and  the  pouch  of  Douglas  may  be  pre- 
vented by  early  replacement  of  the  organ,  by  plugging  and 
by  massage,  and  similar  treatment  may  be  employed  for 
the  troubles  connected  with  micturition  and  defaecation. 

Special  care  must  be  observed  in  cases  of  retroflexion 
which  are  complicated  by  pregnancy.  Although  in  most 
cases  spontaneous  replacement  occurs  in  the  second  or  third 

303 


THE   PREVENTION  OF   DISEASE 

month,  yet  when  this  fails  to  take  place  serious  and  even 
dangerous  symptoms  may  arise.  In  neuropathic  patients, 
excessive  vomiting  may  occur,  and  difficulty  of  micturition 
which  may  lead  to  gangrene  of  the  bladder  wall.  These 
are  the  results  of  retroflexion  of  the  incarcerated  gravid 
uterus.  The  replacement  of  the  uterus  in  the  second  or 
third  month  and  the  wearing  of  a  pessary  till  the  fifth 
month  will  prevent  this. 

For  other  complications  and  sequelae  reference  must  be 
made  to  what  has  been  said  under  "  Prolapse." 

In  conclusion  I  must  mention  elevation  and  torsion  of  the 
uterus,  both  of  which  as  a  rule  are  combined  with  other 
pathological  displacements.  They  are  caused  by  tumours 
or  inflammatory  adhesions  or  by  the  distension  of  some 
neighbouring  organ.  Pathological  rotation  of  the  uterus, 
especially  that  caused  by  tumours,  may  bring  about 
very  serious  circulatory  disturbances  and  necrosis  of  the 
uterine  wall,  or  even  a  tearing  of  the  tissues.  Such 
occurrences  should  be  prevented  by  a  radical  operation,  or 
if  this  is  refused  by  the  use  of  a  closely  fitting  abdominal 
belt. 

III.     Disturbances  in  Nutrition  and 

Inflammations 

(a)  The  preventive  treatment  in  disorders  of  nutrition  and 
of  circulation. 

Vascular  engorgement  in  consequence  of  vasomotor  dis- 
turbances has  been  frequently  mentioned  in  the  foregoing 
pages,  and  we  found  it  generally  associated  with  changes 
in  form  and  in  position  of  the  internal  generative  organs. 
These  changes  owe  their  origin  to  a  similar  loss  of  tone  of 
the  elastic  elements  in  the  walls  of  the  organs  and  their 
ligaments.  In  its  further  course  such  hyperaemia  leads 
on  to  inflammation,  not  infective  in  origin  yet  the 
abnormal  secretion  of  mucus  is  well  adapted  to  serve  as  a 
nidus  for  bacteria ;  yeast  cells  and  amoebae  have  also  been 
found. 

A   definite   set   of    symptoms   arises   from    this  source  : 

304     - 


PROPHYLAXIS   IN   THE   DISEASES   OF   WOMEN 

pruritus  of  the  vulva,  vaginismus  and  dysmenorrhoea.  In 
more  severe  cases  there  may  also  be  tenesmus  of  the  rectum 
and  bladder,  and  uterine  colic. 

Preventive  measures  consist  chiefly  in  general  tonic 
treatment,  as  already  described  under  "  The  Infantile  Con- 
dition," "  Herniae  "  and  "  Prolapse." 

An  aetiological  factor  which  is  of  great  and  frequent 
importance,  closely  connected  with  neurotic  conditions  and 
hysteria,  in  this  group  of  disorders  is  the  existence  of  per- 
verted sexual  habits,  such  as  masturbation  and  onanism, 
and  sexual  over-stimulation.  On  the  other  hand  these  morbid 
conditions  may  be  associated  with  impotence  in  the  male. 
Pruritus  and  vaginismus,  as  well  as  neuralgia  of  the 
posterior  vaginal  vault,  have  in  many  cases  been  readily 
proved  to  have  a  causal  connexion  therewith.  These  two 
factors  constitute  a  vicious  circle.  In  a  girl  thus  predisposed 
we  must  insist  upon  her  performing  household  duties 
which  shall  fully  occupy  her  time,  and  upon  the  avoidance 
of  all  such  things  as  tend  to  stimulate  the  sensual  nature 
and  the  imagination,  such  as  lectures,  balls  and  the  theatre. 
When  nearing  maturity  such  girls  should  be  under  the 
care  of  a  sensible  mother,  and  not  in  a  girls'  boarding 
school,  very  few  indeed  of  which  are  in  a  position  to  give 
to  each  individual  girl  the  special  training  she  requires,  and 
which  afford  scope  for  numerous  follies  that  injure  both 
body  and  mind.  An  occupation  in  which  mental  work  pre- 
ponderates is  useless.  We  must  note  that  masturbation  is 
sometimes  seen  in  quite  young  children.  It  is  sometimes 
caused  by  the  irritation  of  thread  worms,  and  these  should 
be  looked  for  and  treated  ;  in  other  cases  it  is  due  to  vesical 
calculi,  or  to  fissures  in  the  region  of  the  clitoris  or  hymen. 
These  fissures  often  give  rise  to  vaginismus,  analogous  to 
the  tenesmus  of  the  anus  caused  by  anal  fissures.  They 
are  most  quickly  cured  by  dabbing  with  ichthyol. 

Pruritis  of  the  vulva  is  often  caused  by  diabetes. 

Vulvitis  is  caused  too  by  want  of  cleanliness,  especially 
when  leucorrhoea  exists  or  marked  enlargement  of  the 
labia  and  clitoris.  Cleanliness,  bathing  with  lotions  which 
are  antiseptic  and  astringent,  such  as  lead  lotion,  powdering 

305  X 


THE  PREVENTION  OF  DISEASE 

with  salicylic  acid  and  talc,  or  bismiitli  and  talc,  will 
prevent  the  inflammation  becoming  worse.  "When  there  is 
a  tendency  to  the  formation  of  boils,  the  eruption  may  be 
checked  by  the  immediate  use  of  Unna's  mercurial  carbolic 
plaster  upon  the  tender  spots  which  are  just  becoming  red. 
Lotions  of  sodium  carbonate  may  be  used  for  folliculitis. 

With  regard  to  vaginismus,  we  must  not  forget  that  it 
may  be  hysterical  in  origin  and  arise  from  a  fixed  dread 
of  connexion.  In  other  cases  there  is  inflammatory 
hypertrophy  of  the  hymen.  A  pretended  or  an  actual 
excision  of  the  hjmien  and  the  orifice  of  the  urethra, 
followed  by  the  passage  of  a  speculum,  will  convince  the 
patient  that  the  vagina  can  now  be  easily  entered,  and 
vaginismus  will  then  be  less  likely  to  recur.  "We  must 
remove  also  all  other  contributing  factors,  such  as  fissures 
and  perverted  habits. 

The  same  holds  good  for  neuroses  affecting  the  upj)er 
part  of  the  vagina. 

Varicose  veins  are  not  seldom  met  with  in  the  broad 
ligaments  and  in  the  nymphae.  The  latter  condition  as 
well  as  the  troublesome  sequelae,  such  as  the  rupture  of  the 
varicose  veins  and  the  formation  of  haematoma  of  the 
vulva  and  thrombosis,  may  be  prevented  during  pregnancy 
by  compression  with  a  T  bandage  witha dressing  steeped  in 
astringent  lotion  ;  and  the  external  genitals  should  be  kept 
scrupulously  clean. 

By  the  bursting  of  varicose  veins  of  the  broad  ligament 
an  intraperitoneal  haematoma  or  a  haematoma  of  the 
broad  ligament  may  arise,  and  for  this  reason  they  should 
not  be  neglected.  By  way  of  prevention  hot  mucilaginous 
vaginal  and  rectal  injections  should  be  given,  the  regular 
evacuation  of  the  bowels  should  be  ensured,  and  compression 
be  applied  by  j)lugging,  as  by  a  bag  of  shot  in  the  vagina 
and  also  upon  the  abdomen,  and  cautious  bimanual 
massage.  The  patient  should  afterwards  rest  for  an  hour 
in  the  recumbent  position. 

The  so-called  neuralgia  of  the  ovary  has  nothing  to  do 
with  the  ovaries,  and  but  seldom  with  the  adjacent  nerve 
plexuses ;  but  is  generally  neuralgia  of  the  nerves  passing 

306 


PROPHYLAXIS  IN  THE  DISEASES  OF  WOMEN 

througli  the  recti  muscles  towards  tlie  hypogastriiim,  or 
neuralgia  of  the  posterior  vaginal  vault  and  of  Douglas' 
pouch  and  the  adjacent  part  of  the  rectum.  If  the  pain 
radiates  downwards,  it  is  felt  according  to  my  observations 
in  the  region  of  the  coccyx  and  anus;  apart  from  this  there 
is  also  a  true  coccygodynia.  For  all  these  conditions,  pre- 
ventive treatment  consists  in  the  treatment  of  the  general 
neurasthenia  and  of  the  local  congestions  caused  by  it. 
Only  very  seldom  do  we  find  actual  periostitis  or  dislocation 
in  coccygodynia. 

The  congestive  inflammations  of  the  vagina,  uterus  and 
ovaries,  and  the  dysmenorrhoea  associated  with  these,  have 
already  been  dealt  with. 

(b)  The  preventive  treatment  of  inflanimations  and  their 
sequelae. 

There  is,  as  mentioned  above,  an  inflammation  of  the 
generative  organs,  which  is  not  infective  in  origin.  The 
exciting  cause  of  infective  inflammations  is  infection  with 
microbes,  among  which  gonococci,  staphylococci  and 
streptococci  play  by  far  the  most  important  part.  Their 
entry  is  brought  about  by  sexual  connexion  or  by  labour, 
by  operations,  by  foreign  bodies,  by  injuries,  or  by  trans- 
ference from  other  organs  as  in  the  case  of  tuberculosis, 
and  of  the  bacterium  coli.  As  already  stated,  the  presence 
of  bacteria  in  the  secretions  of  the  uterus  and  the  presence 
of  the  yeast  fungus  must  not  always  be  regarded  as  the 
cause  of  the  inflammation.  These  organisms  have  settled 
there  because  the  secretions  had  become  pathological,  or 
because  the  entrance  of  the  vagina  and  the  cervical  canal 
had  received  injuries  and  been  dilated.  The  primary  cause 
is  to  be  found  in  the  congestion,  hyperaemia  and  engorge- 
ment as  often  mentioned  above,  as  the  result  of  disorders  in 
innervation  and  conditions  of  relaxation  of  the  pelvic  and 
abdominal  organs.  In  accordance  with  this,  these  in- 
flammations do  not  finally  disappear  until  the  tone  of  the 
general  and  local  innervation  has  been  raised. 

And  conversely  the  cause  of  the  congestive  hyperaemia 
and  engorgement  may  originally  have  been  infective  in- 
flammations, which  were  cured  when  the  bacteria  had  died 

307 


THE  PREVENTION  OF  DISEASE 

out  or  had  lost  their  virulence  and  which  left  behind  a 
diminished  contractility  of  all  the  elastic  tissue  elements, 
including  those  of  the  vessels.  These  infective  inflamma- 
tions may  have  occurred  even  in  early  childhood  from 
scarlatina,  measles  or  gonorrhoea. 

It  is  very  important  then  to  avoid  the  introduction  of 
infective  germs  into  the  internal  genitalia,  because  these 
organisms  readily  make  their  way  along  the  mucous  mem- 
brane of  the  Fallopian  tubes  to  the  pelvic  peritoneum,  or 
pass  through  the  uterine  wall  to  the  parametrium  and 
spread  to  the  ovary.  If  they  have  entered  the  vagina, 
they  should  be  removed  before  they  pass  the  internal  os. 
"When  the  acute  infective  inflammation  has  subsided  care 
must  be  taken  that  no  congestion  of  the  organs  and  liga- 
mentous apparatus  remains  or  loss  of  elasticity — and  on  the 
other  hand  that  no  contractions  and  adhesions  exist  to 
produce  permanent  displacement  of  the  uterus. 

1.  GONOREHOEA 

is  the  most  frequent  cause  of  infective  inflammations  of  the 
genitalia.     It  should  be  remembered  that 

(a)  In  recent  acute  infection  the  internal  os  uteri  and 
afterwards  the  uterine  orifices  of  the  Fallopian  tubes  are  able 
for  a  long  time  to  resist  the  further  passage  of  the  infection, 
and  hence  acute  infection  vary  rarely  leads  directly  to 
salpingitis  or  perimetritis. 

(&)  That  chronic  gonorrhoea  is  the  form  in  which  it 
appears  most  often  in  married  life,  and  is  caused  by  latent 
gleet  in  the  male  ;  and  in  spite  of  or  possibly  by  reason  of 
its  very  slowly  progressive  course  it  at  last  reaches  the 
serous  membrane. 

The  preventive  treatment  of  gonorrhoea  belongs  to  the 
section  on  Venereal  Disorders.  But  so  far  as  gynaecology  is 
concerned,  and  in  order  that  the  patient  innocently  exposed 
to  this  infection  may  be  relieved,  the  husband  must  be  cured 
of  his  gonorrhoea  or  gleet,  and  coitus  should  be  avoided  till 
he  is  cured,  and  again  later  after  any  alcoholic  or  venereal 
excess.  In  other  words  all  over-stimulation  reacts  upon 
the  cocci  concealed  in  the  deep  crypts,  and  this  fact  is  the 

308 


PROPHYLAXIS  IN  THE  DISEASES   OF  WOMEN 

more  important  because  it  is  doubtful  wliether  such  cases 
are  ever  completely  cured.  Antigonorrlioeal  applications  in 
the  form  of  pastilles,  of  vaginal  suppositories,  or  as  douches 
or  as  insufflation  are  useful  if  used  both  before  and  after 
coitus,  but  they  are  not  absolutely  certain,  and  tend  to  pre- 
vent conception.  All  local  treatment  at  such  times  acts 
injuriously  upon  the  nervous  system  especially  in  those 
with  a  neuropathic  predisposition.  Cold  irrigations  should 
be  altogether  avoided  as  they  cause  metritis,  parametritis 
and  oSphoritis  by  disturbance  of  the  circulation. 

"When  infection  has  taken  place  treatment  is  essential 
to  prevent  its  extension  to  the  internal  os  uteri :  vaginal 
douching  five  times  daily  with  solutions  of  silver  salts 
and  under  very  slight  pressure — such  as  a  5  per  cent. 
solution  of  protargol,  a  5  to  10  per  cent,  solution  of 
argonin,  a  5  per  cent,  solution  of  argentamin  in  cases 
where  treatment  of  the  deeper  structures  is  required,  6  to 
20  per  cent,  solution  of  silver  nitrate  as  an  astringent  for 
after  treatment,  a  5  per  cent,  solution  of  largin  which  is  a 
powerful  antiseptic  to  the  gonococcus  though  with  very 
slight  action  upon  the  nutritive  medium.  The  vulva  must 
be  scrupulously  cleansed  to  prevent  reinfection  and  urethri- 
tis, or  cystitis,  or  inflammation  of  Bartholin's  glands. 

If  cervicitis  appears  the  cervical  canal  should  be  dilated 
after  disinfection  with  protargol,  and  the  uterine  cavity 
treated  by  cleansing,  douching,  plugging,  and  the  use  of 
pencils  or  ointments  (from  ^  to  10  per  cent,  of  protargol), 
while  the  patient  remains  at  absolute  rest  in  bed.  Finally, 
treatment  should  be  continued  for  several  weeks  longer 
with  potassium  permanganate,  and  lastly  with  astringents 
to  remove  the  oedematous  condition  which  is  left  behind  :  a 
2  to  5  per  cent,  solution  of  aluminium  acetate  or  a  2  to  3 
per  cent,  of  bismuth  subnitrate  may  be  employed. 

If  for  other  reasons  this  thorough  treatment  cannot  be 
carried  out  vaginal  douches  should  be  ordered  ;  they  may 
consist  of  a  5  per  cent,  solution  of  protargol,  or  5  to  20  per 
cent,  solution  of  silver  nitrate  or  potassium  permanganate, 
or  a  1  in  2,000  or  4,000  solution  of  corrosive  sublimate. 
The  vagina  should  be  wiped  out  and  plugged  several  times 

309 


THE  PREVENTION  OF  DISEASE 

a  week  with  a  10  per  cent,  protargol  gauze,  or  the  patient 
should  herself  a23ply  10  per  cent,  protargol  glj^cerine  plugs. 
The  cervix  should  not  be  treated. 

With  a  pyosalpinx,  bilateral  as  a  rule  in  cases  of 
gonorrhoea,  extension  to  the  peritoneum  must  be  pre- 
vented. Simple  salpingitis  can  be  cured  by  sedative  treat- 
ment, mercury  and  rest  in  bed,  before  a  pyosalpinx  forms. 
An  operation  for  removal  of  the  tube  is  indicated  when 
suppuration  threatens.  Even  after  recovery  from  the 
perimetritis  the  danger  of  subsequent  attacks  is  great,  and 
for  this  reason  the  parts  should  be  removed;  they  have 
already  become  useless.  Otherwise  the  only  preventive 
treatment  possible  is  to  lead  a  very  regular  life,  and  avoid 
colds  and  cold  feet.  For  attacks  of  pain  however  slight 
apply  an  ice  bag  or  at  least  cold  compresses,  and  the  patient 
must  rest  in  bed.  By  preventing  the  inflammation  of  the 
uterus  from  becoming  chronic  we  prevent  also  the  joint 
affections  which  may  gradually  and  insidiously  through 
the  circulation  affect  all   the  joints. 

2.  ACUTE  SEPSIS 

is  prevented  by  strict  asepsis  and  antisepsis  at  operations. 
When  an  abscess  is  to  be  opened  in  or  near  the  abdominal 
cavity,  the  suppurative  focus  should  be  caref uU}''  isolated  bj'- 
gauze  pads  before  the  incision  into  the  abscess  is  made. 
Should  the  pus  nevertheless  escape  into  the  abdominal 
cavity  it  should  be  carefully  mopjDed  out  and  the  peritoneum 
drained  with  iodoform  gauze  or  itrol  gauze  brought  out 
through  the  vagina  or  the  lower  angle  of  the  abdominal 
wound.  The  germs  contained  in  old  cases  of  salpingitis 
have  but  slight  virulence  or  are  dead.  Infected  wounds 
should  be  disinfected  as  thoroughly  as  possible  and  should 
be  daily  dressed  with  iodoform  or  itrol  gauze.  Immediate 
treatment  is  the  surest  way  of  preventing  the  extension  of 
the  sepsis  to  the  parametrium,  the  peritoneum  or  to  the 
lymph  or  blood  stream. 

The  prevention  of  puerperal  sepsis  is  dealt  with  under 
the  hygiene  of  parturition,  to  which  the  reader  is 
referred. 

310 


PROPHYLAXIS  IN  THE    DISEASES   OP    WOMEX 

3.  ACUTE  INFLAMMATIONS  OF  THE  GENITALIA 

These  are  vulvitis,  colpitis,  endometritis,  parametritis 
and  perimetritis,  and  ooplioritis.  They  are  mostly  of 
gonorrhoeal  or  of  septic  origin :  besides  streptococci,  we 
find  staphylococci,  bacterium  coli  and  pneiimococci  as  the 
exciting  cause.  Cases  of  colpitis  and  of  endometritis  of 
this  nature  are  occasionally  caused  by  wearing  a  pessary 
for  too  long  a  time,  or  by  the  use  of  dirty  or  rough 
pessaries,  by  curetting  or  use  of  the  uterine  sound  without 
previously  sterilizing  the  instruments,  and  even  by  rough 
exploration  with  infected  fingers.  From  what  has  been 
said  it  is  obvious  that  the  preventive  treatment  consists  in 
strict  asepsis  and  antisepsis.  And  further  these  inflamma- 
tions may  appear  as  complications  in  general  acute 
infections  diseases,  as  scarlatina,  measles,  smallpox,  typhoid 
fever,  cholera,  and  influenza,  and  in  these  preventive  treat- 
ment should  aim  at  removing  the  congestion  which  has  been 
left  by  the  acute  disease. 

Finally  in  colds  accompanied  hy  suppression  of  the 
menses  we  may  meet,  not  only  with  acute  cystitis  and 
metritis,  buV  also  with  parametritis  and  oophoritis. 
Immediate  confinement  to  bed,  the  production  of  dia- 
phoresis, cold  abdominal  compresses  or  an  ice  bag,  local 
blood  letting,  mild  purgation,  and  hot  vaginal  douches  are 
indicated  for  this  as  well  as  for  all  other  acute  inflamma- 
tions of  the  genitalia. 

Acute  vulvitis  often  originates  in  slight  injuries  and 
fissures  which  have  not  been  kept  clean.  Cauterization 
and  subsequent  treatment  with  aluminium  acetate  will 
prevent  the  formation  of  ulcers  and  abscesses. 

4.  CEEYICAL  CATAERH  AND  ITS  SEQUELAE,  EYEESION 
AND  EROSION 

Preventive  treatment  consists  in  the  removal  of  circula- 
tory disturbances  and  of  displacements,  and  the  removal  of 
scar  tissue  from  the  os  uteri  (laceration  scars).  The  scar 
tissue  should  be  excised  and  the  raw  surfaces  united  by 
catgut  sutures. 

311 


THE  PREVENTION   Or  DISEASE 

Erosions,  especially'-  old  erosions  of  papilloid  form,  have 
sometimes  been  observed  to  nndergo  cancerous  degenera- 
tion. To  avoid  this  danger  it  is  wise  to  remove  the  diseased 
mucous  membrane  by  excision  according  to  Scbroeder's 
metliod,  by  wliich  the  cervical  wall  including  tbat  of  tbe 
vaginal  portion  of  tbe  cervix  is  reduced  to  one  half  its 
thickness.  Catgut  sutures  are  then  passed  from  the 
internal  os  to  the  external  os,  and  after  turning  over  the 
flaps  are  tied  so  that  tlie  line  of  the  former  external  os  is 
now  applied  to  the  internal  os. 

For  the  treatment  of  eversion  produced  b}''  unsuitable 
pessaries  when  the  walls  of  the  cervix  are  relaxed  and  there 
are  no  lacerations  of  the  os  see  under  "  Prolapse." 

5,  PEEVENTIVE   TREATMENT  IN  CHRONIC  ENDOMETRITIS 
AND  METRITIS  OF  THE  BODY  OF  THE  UTERUS 

The  longer  these  chronic  catarrhal  inflammations  have 
existed,  with  over  secretion  of  mucus  and  pus,  the  more 
readily  do  they  bring  about  structural  changes  in  the 
endometrium  and  in  the  uterine  wall.  The  sooner  the 
treatment  is  commenced,  the  more  easily  and  the  more 
completely  will  the  affected  parts  be  restored  to  their 
normal  condition. 

Endometi^itis  should  not  be  regarded  with  indifference, 
and  to  look  upon  everj^  discharge  as  a  condition  which 
presumabl}^  need  not  be  treated  or  is  quite  irrelevant  is 
indifference  which  cannot  be  justified  ;  it  causes  an  un- 
necessary loss  of  secretion,  of  blood  and  of  the  patient's 
strength,  and  predisposes  to  puerperal  fever,  and  later 
affords  a  favourable  site  for  carcinoma  and  a  number  of 
other  morbid  conditions. 

Chronic  metritis  may  follow  every  acute  form  of  metritis 
and  also  puerj^eral  infective  processes.  Very  often  it  is 
the  immediate  result  of  a  simple  non-infective  condition  of 
congestion  and  of  relaxation,  and  for  this  reason  is  always 
met  with  in  retroversion  and  descent  of  the  uterus. 
Hence  too  it  is  the  sequela  of  all  processes  which  cause 
frequent  congestion  such  as  masturbation,  excessive  sexual 
intercourse,  cold  and  irritating  vaginal  douches,  suppression 

312 


PROPHYLAXIS   IN  THE  DISEASES   OP   WOMEN 

of  the  menses  and  colds.  Subinvolution  of  the  uterus 
also  is  likely  to  give  rise  to  metritis,  especially  when  the 
subinvolution  occurs  after  miscarriage,  or  after  failure  to 
suckle  the  infant  though  there  is  sufficient  milk  in  the 
breasts  ;  these  occasional  determining  causes  bring  about 
the  result  probably  because  a  neuropathic  predisposition 
already  exists. 

Upon  the  soil  thus  provided  by  chronic  endometritis, 
erosions  and  eversions  may  develop,  and  solitary  or 
multiple  adenomatous  new  growths  (polypi)  may  form. 
Preventive  treatment  should  concern  itself  with  the  avoid- 
ance or  speedy  removal  of  all  infection  on  the  one  hand, 
and  on  the  other  hand  with  the  removal  of  general  and  local 
disturbances  in  innervation  as  has  already  been  stated. 

And  further  we  must  see  that  simple  catarrhal  endo- 
metritis does  not  become  haemorrhagic  or  purulent,  and  so 
lay  the  foundation  for  structural  changes  and  for  adeno- 
matous growths. 

A  free  outlet  for  the  secretion  must  be  provided,  and  may 
necessitate  a  dilating  of  the  cervical  canal ;  the  vagina 
should  be  washed  out  several  times  a  day  with  lukewarm 
or  hot  normal  saline  solution,  the  patient  being  in  the 
recumbent  posture.  Astringents  and  antiseptics  are 
generally  added  without  much  discrimination.  Astringents 
are  suitable  for  erosion  and  eversion,  though  cauterization 
through  the  speculum  is  more  effectual,  and  for  vaginitis. 
Antiseptics  are  best  for  infective  or  septic  inflammations — 
but  long  continued  applications  and  strong  irritating  anti- 
septics should  be  avoided.  Hot  douches  excite  contraction 
of  the  uterus  and  thus  tend  to  expel  the  secretion.  This 
may  be  assisted  by  the  administration  of  ergot ;  or  by  the 
use  of  stypticin  and  hydrastis  immediately  before  the 
commencement  of  the  period  we  may  act  upon  the 
vasomotor  system  in  monorrhagia.  During  the  first  stage 
of  metritis,  that  of  hyperaemia,  cotton  wool  pledgets 
soaked  in  glycerine  and  placed  in  the  vagina  produce 
depletion  and  stimulate  the  uterus  to  contract,  and  this 
may  be  combined  with  compression  by  means  of  bags  of 
shot  in  the  vagina  and  on  the  abdomen. 

313 


THE  PREVENTION  OF  DISEASE 

During  the  menstrual  period  there  is  diminished  power 
of  resistance  against  injurious  processes,  and  these  must 
therefore  be  especially  avoided  at  this  time.  Among  them 
must  be  mentioned  colds  and  cold  feet,  errors  in  diet,  con- 
stipation, habitual  overfilling  of  the  bladder,  long  journeys 
by  rail  or  by  coach,  river  bathing,  balls,  heavy  lifting,  over- 
exertion, sexual  stimulation.  In  those  who  are  thus  pre- 
disposed, proper  precautions  should  be  taken  after  mis- 
carriage and  during  the  puerperium :  two  weeks'  rest  in 
bed,  then  the  administration  of  ergot,  the  use  of  cold  water 
compresses  and  abdominal  massage,  and  if  possible  the  child 
should  be  suckled  ;  hot  vaginal  injections  and  the  insertion 
of  a  pessary  in  the  second  week  are  also  of  value.  These 
measures  prevent  dysmenorrhoea  ;  they  are  aided  by  timely 
scarification  of  the  vaginal  cervix  and  removal  of  two  or 
three  tablespoonfuls  of  blood,  or  by  wedge  shaped  excisions 
from  the  vaginal  cervix.  If  the  process  has  already  become 
chronic  then  after  dilatation  a  change  of  conditions  is 
brought  about  by  cauterizing  once  or  twice  a  week  with  a 
sound  wrapped  round  with  cotton  wool  dipped  in  a  five  per 
cent,  solution  of  zinc  chloride.  Stronger  and  more  frequent 
cauterization  is  contra  indicated  by  reason  of  the  possibility 
of  the  formation  of  scar  tissue  and  adhesions. 

But  the  infective  agent  must  also  be  combated,  in 
suitable  cases,  by  iodoform,  or  by  silver  salts  in  the  form  of 
pencils  or  ointments.  Abel  recommejids  plugging  the  uterus 
with  iodoform  gauze.  For  the  purpose  of  "  biological  dis- 
placement "  Landau  introduced  yeast  cultures.  The  plug 
at  the  same  time  stimulates  contraction. 

When  once  swelling  of  the  mucous  membrane  is  present, 
the  possibility  of  further  development  may  be  prevented  by 
curetting,  after  dilatation  of  the  cervix  and  the  subsequent 
application  of  liquor  ferri  perchloridi  or  tinctura  iodi 
twice  daily  by  means  of  a  sound  after  the  uterus  has  been 
washed  out,  or  steam  may  be  applied  at  a  temperature  of 
220°  F.  for  not  more  than  a  quarter  to  half  a  minute.  The 
author  has  found  the  latter  process  very  useful  in  obstinate 
cases  with  metritis,  but  it  must  never  be  used  while  the 
patient  is  allowed  to   go  about,  and  in  some  patients  it 

314 


PEOPHYLAXIS  IN  THE  DISEASES  OF  WOMEN 

must  be  performed  under  an  anaesthetic  and  always  after 
dilatation  and  measurement  of  the  uterus  to  avoid  perfora- 
tion of  tlie  uterine  wall.  The  organ  contracts  vigorouslj'- 
under  the  action  of  the  steam,  and  in  order  to  avoid  local 
effects  by  the  heated  metal  the  apparatus  should  be  slowly 
rotated  and  moved  about.  The  method  must  not  be  used 
by  any  one  who  is  not  skilled  in  gynaecology.  My  own 
experience  is  that  it  not  only  checks  haemorrhage  and 
suppuration,  purposes  for  which  it  was  introduced,  but  that 
it  acts  as  an  alterative  unlike  any  other  treatment. 

G.    PREVENTIVE  TREATMENT    IN  CHRONIC 
PARAMETRITIS 

In  cases  which  have  developed  out  of  an  acute  para- 
metritis and  which  are  characterized  by  contraction  of  the 
residual  products  and  the  formation  of  scar  tissue,  or  by 
slowness  in  the  absorption  of  the  exudation  products, 
associated  with  small  abscesses  which  cannot  properly  dis- 
charge their  contents,  we  must  endeavour  as  soon  as  the  fever 
and  pain  have  ceased,  to  remove  the  residual  products  of  the 
parametritis,  in  order  that  no  firm  fibrous  bauds  may 
arise,  for  these  are  difficult  to  treat  and  lead  to  dis- 
placement, flexions  and  strain  upon  the  pelvic  organs. 
Treatment  should  consist  of  massage,  aided  by  hot  vaginal 
douches  and  by  plugging,  which  is  best  performed  by  a 
dilatable  iudiarubber  bag. 

The  long  dela}^  in  the  absorption  of  exudations  and  the 
loss  of  strength  produced  by  the  suppuration  must  be  met 
by  measures  which  tend  to  promote  absorption,  such  as 
the  introduction  of  tampons  with  glycerine,  iodine  and 
potassium  iodide,  combined  with  compression  by  means  of 
bags  of  shot  placed  in  the  vagina  and  on  the  abdomen,  and  hot 
vaginal  and  rectal  injections  at  a  temperature  of  90°  F.  to 
100°  F.;  a  few  litres  may  be  administered  several  times 
daily  the  patient  being  recumbent.  Massage  may  be  used 
but  with  caution,  and  hot  sand  baths  and  saline  baths  may 
be  given,  and  the  patient  should  have  a  nutritious  diet. 
Should  pyrexia  occur  the  treatment  must  be  discontinued 
.and  cold  water  compresses  must  be  applied  to  the  abdomen. 

315 


THE  PREVENTION   OE  DISEASE 

Intra-nterine  treatment  must  never  be  used.  Care  should 
be  taken  that  the  bowels  are  freely  open. 

There  is  too  an  atrophic  form  of  parametritis,  which  is 
produced  by  over  stimulation  of  the  genital  nerves  and  long- 
continued  loss  by  over  secretion  ;  this  is  due  to  frequent 
pregnancies  with  lactation  in  the  intervals,  and  to  sexual 
excesses.  It  consists  of  a  fibrosis  of  the  connective  tissues 
following  upon  a  periphlebitis  which  starts  in  the  liga- 
ments and  ultimately  involves  the  whole  genital  tract. 
Preventive  treatment  should  be  directed  against  these 
injurious  causes,  especially  against  masturbation.  The 
further  progress  of  the  fibrosis  may  be  prevented  by  hot 
vaginal  douches,  the  use  of  the  vaginal  thermophore,  and 
hip  baths,  massage,  intra-uterine  stimulation  by  tents,  the 
use  of  intra-uterine  tampons  and  irrigation  with  a  solution 
of  sodium  carbonate. 

Apart  from  infection  we  find  a  traumatic  non-infective  con- 
traction of  the  parametrium  after  laceration  occurring  during 
labour  or  after  injuries  caused  by  a  sudden  fall  or  by  heavy 
lifting.  The  injury  often  does  not  obviously  involve  the 
vagina.  But  if  such  contractions  are  diagnosed  it  is  well 
to  stretch  them  early,  or  to  excise  the  scars  and  stitch  the 
parts  in  such  a  wsij  that  the  contracted  part  in  the 
vaginal  vault  may  be  widened. 

7.   PEEVENTIVE  TEEATMENT  IN  CHRONIC  OOPHORITIS 

The  chronic  form  which  is  derived  from  the  acute  form 
of  oophoritis,  whether  gonorrhoeal  or  septic,  arises  through 
infection  by  the  Ij^mphatics,  or  more  frequently  by  the 
direct  extension  of  a  salpingitis.  This  condition  is  in- 
separable from  perimetritis  involving  the  tube  and  ovary 
and  will  be  considered  subsequently. 

It  is  otherwise  with  fibrosis  of  the  ovary,  which  finally 
leads  to  complete  destruction  of  all  the  follicles  by  the 
formation  of  fibrous  tissue.  Preventive  treatment  consists 
in  the  avoidance  of  all  that  would  lead  to  congestion  ;  there 
should  be  sexual  abstinence,  a  discontinuance  of  pernicious 
habits  and  over  stimulation ;  the  bowels  must  be  regularly 
evacuated,  hot  vaginal  and  rectal  injections,  or  hot  and  cold 

316 


PROPHYLAXIS  IN  THE  DISEASES  OE  WOMEN 

vaginal  douches  at  temperatures  of  60°  F.  and  90°  F. 
alternately,  treatment  by  compression,  and  at  night  a 
cold  water  compress  may  be  employed. 

8.  PEEVENTIVE  TREATMENT  IN  CHRONIC  PERIMETRITIS 
WITH  SALPINGITIS  AND  OOPHORITIS,  AND  PELVIC 
PERITONITIS. 

Prophylaxis  consists  on  the  one  hand  in  treatment  of 
the  corresponding  acute  inflammation  or  of  the  primary 
focus,  whether  a  metritis,  a  parametritis,  an  oophoritis,  or 
a  salpingitis,  generally  septic  or  gonorrhoeal  in  origin,  and 
on  the  other  hand  in  checking  the  further  extension  of  the 
primary  focus  of  infection. 

This  is  best  effected  by  active  measures :  such  as  an 
ice  bag,  a  cold  water  compress,  and  the  local  abstrac- 
tion of  blood.  Lukewarm  mucilaginous  or  saline  irrigation 
of  the  vagina  under  slight  pressure  should  be  employed, 
together  with  the  application  of  substances  which  are 
antiseptic  and  tend  to  cause  absorption  by  the  blood  and 
lymph  channels.  Care  should  be  taken  that  the  skin, 
kidneys  and  bowels  act  freely  in  order  to  get  rid  of  the 
toxine.  A  nourishing  diet  is  important,  and  later  on 
stimulation  of  the  heart  by  alcohol  and  by  friction. 

"When  the  acute  stage  is  over,  the  slow  transition  into  a 
chronic  stage  must  be  prevented  by  energetic  treatment 
to  promote  absorption,  such  as  mud  baths,  hot  sand  baths, 
saline  baths,  vaginal  and  abdominal  compression,  vaginal 
thermophore  and  tampons,  with  glycerine,  iodine  and 
potassium  iodide,  hot  vaginal  douches,  and  a  nourishing 
diet.  Later,  massage  may  be  used,  partly  to  hasten  absorp- 
tion, partly  to  prevent  displacement  and  fixation  of  the 
uterus  and  ovaries. 

If  a  localized  pelvic  peritonitis  has  been  formed  by  the 
adhesion  of  a  coil  of  intestine  across  the  pouch  of  Douglas, 
rest  is  needed  to  prevent  a  general  peritonitis.  The  intes- 
tine is  placed  at  rest  by  tinctura  opii,  or  if  there  is  pro- 
fuse diarrhoea  by  extract  of  opium  with  bismuth  subnitrate. 
In  this  condition  any  interference  with  the  internal 
genitalia  is  contra-indicated. 

317 


THE  PREVENTION  OE  DISEASE 

(xoiiorrlioeal  pelvic  peritonitis  is  a23t  to  recur,  and  there- 
iore  to  prevent  these  recurrent  attacks  of  fever  whicli 
confine  the  patient  to  bed  for  weeks  at  a  time,  it  msij  he 
advisable  to  perform  a  vaginal  or  suprapubic  hyster- 
ectomy. 

AVhen  encapsuled  intraperitoneal  abscesses  form,  it  is 
most  important  to  provide  a  safe  and  free  outlet  for  the 
pus.  Perforation  of  the  rectum  brings  with  it  the  risk  of 
decomposition,  a  passage  for  the  pus  should  therefore  be 
made  through  the  vagina.  Should  it  open  into  the  bladder 
an  ascending  pyelonephritis  may  be  set  up,  and  to  prevent 
this  it  may  be  necessary  to  make  a  temporary  vesical 
fistula  by  a  suprapubic  cystotomy  or  by  an  incision 
through  the  vaginal  wall. 

9.   PEEVENTITE   TREATMENT   IN   TUBERCULOSIS   OF   THE 

GENITALIA 

The  agent  is  the  tubercle  bacillus,  and  its  entry  is 
favoured  by  a  general  predisj)Osition.  There  seems  how- 
ever to  be  also  a  local  predisposition  to  it  after  gonorrhoeal 
or  septic  infection  or  mixed  infection,  and  also  when 
fissures  appear  in  the  epithelium  of  the  vagina  or  vulva. 
Such  fissures  make  it  easy  for  primary  tuberculosis  of  the 
genitals  to  be  produced  by  coitus,  or  by  examination  with 
an  infected  finger,  or  by  infected  linen  and  similar  oc- 
casional exciting  causes. 

Secondary  tuberculosis  is  more  frequent,  and  arises  through 
the  circulation,  as  from  tuberculous  disease  of  the  intes- 
tines, lungs  or  kidneys.  Infection  may  pass  to  the  genera- 
tive organs  by  the  lymph  path,  or  by  infection  of  a 
Fallopian  tube  from  the  peritoneum,  which  is  the  most 
frequent  of  all.  It  may  be  caused  by  contact  with  a 
tuberculous  intestine. 

Preventive  treatment  consists  in  part  in  the  prevention 
of  the  occasional  causes  mentioned  above  and  in  part  in  the 
early  removal  of  inflammations  occurring  in  other  regions. 
It  is  essential  to  raise  the  general  tone  of  the  body.  In 
primary  tuberculous  disease  of  the  genitalia  removal  of  the 

318 


PROPHYLAXIS  IN  THE  DISEASES  OF   WOMEN 

tuberculous  focus  is  indicated  as  a  prophylactic  measure  to 
avoid  a  general  infection  of  the  body.  This  holds  good  also 
for  solitary  ulcers  of  the  vulva  or  bladder.  If  the  ulcer  is 
vesical  excision  is  carried  out  by  the  suprapubic  operation, 
and  iodoform  gauze  tampons  are  used.  Some  writers  have 
recently  recommended  tuberculin  R  for  these  cases.  In 
tuberculosis  of  the  peritoneum  opening  the  abdomen  often 
suffices  to  check  the  progress  of  the  disease,  and  according 
to  Lohlein  opening  the  peritpneum  through  the  vagina 
answers  the  same  purpose. 

10.     PREVENTIVE  TREATMENT  IN  CYSTITIS  REGARDED 
FROM   THE  STANDPOINT  OF  GYNAECOLOGY. 

Vesical  catarrh  may  be  caused,  not  only  by  the  introduc- 
tion of  infectious  germs  into  the  bladder,  but  also  by  injuries 
and  by  disturbances  of  the  circulation ;  both  these  causes 
must  therefore  be  borne  in  mind.  The  most  frequent  ex- 
citing cause  is  catheterization,  by  which  slight  injuries 
may  be  inflicted  at  the  neck  of  the  bladder,  as  may  also 
be  caused  by  calculi  and  other  foreign  bodies.  The  most 
frequent  predisposing  cause  is  cold,  which  produces  a  dis- 
turbance of  the  circulation.  Pathogenic  germs  are  at  all 
times  present  in  the  urethra,  and  bacteria,  especially  the 
bacterium  coli,  get  into  the  bladder  in  spite  of  the  most 
careful  sterilization  of  the  catheter  and  cleansing  of  the 
urethra.  The  difficulty  of  micturition  which  necessitated 
the  use  of  the  catheter  arises  often  from  some  cause  such 
as  paresis  or  bruising,  which  induced  at  the  same  time 
disturbances  of  the  circulation,  so  that  it  is  not  even 
necessary  that  the  catheter  should  first  produce  some 
fissure  or  abrasion  in  order  that  decomposition  of  the  urine 
may  occur  upon  the  soil  produced  by  a  congested  vesical 
mucous  membrane.  These  primary  circulatory  disturb- 
ances of  the  bladder  wall  must  be  removed  by  wet  com- 
presses, hot  spirit  fomentations  on  the  abdomen,  hot  com- 
presses over  the  symphysis  and  urethra,  wet  compresses 
around  the  lower  limbs  or  of  the  whole  body.  We  do 
not  recommend  any  active  treatment  with  antiseptics, 
because   the   frequent  passage   of  the   catheter   is   apt   to 

319 


THE  PREVENTION  OF  DISEASE 

produce   excoriation   of   the   uretliral    mucous    membrane, 
and  thus  provide  a  suitable  nidus  for  germs. 

Alterations  in  the  bladder  wall  may  arise  too  from 
inflammatory  processes  in  the  connective  tissue,  such  as 
parametritis  and  perimetritis,  which  lead  to  exudation  and 
to  suppuration.  Silk  ligatures  and  elastic  ligatures  which 
have  wandered  into  the  bladder  and  tumours  may  also 
cause  disease  of  the  bladder  wall.  It  can  be  seen  by  the 
cystoscope  that  each  perforation  is  preceded  by  hyperaemia 
and  local  swelling  of  the  wall. 

Secondary  vesical  catarrh  is  readily  produced  when 
bacteria  have  been  present  in  the  urine  for  any  length  of 
time,  whether  as  the  result  of  kidney  disease,  such  as 
tuberculosis,  or  of  general  sepsis.  Washing  out  with 
boracic  acid  lotion  and  the  administration  of  salol  are  the 
most  effective  preventive  measures. 

Pathogenic  germs  found  in  the  healthy  urethra  are 
generally  of  a  very  low  degree  of  virulence.  But  it  is 
otherwise  when  infective  vaginitis  is  present  and  its  secre- 
tion flows  round  the  urethral  orifice.  Vaginal  irrigation 
with  antiseptics  is  here  suitable. 

The  severer  cases  of  cystitis  which  have  been  neglected 
lead  to  dangerous  disorders  and  changes  in  the  bladder, 
and  prophylactic  treatment  of  these  sequelae  is  important. 
Among  the  sequelae  are  chronic  vesical  spasm  and  paresis, 
producing  incontinence  or  retention  of  urine  according  to 
the  muscle  which  is  affected.  After  long  existent  cystitis 
the  wall  may  become  hypertrophied  and  the  cavity  reduced 
in  size.  The  latter  may  be  prevented  by  the  injection  of 
fluid  into  the  bladder  in  daily  increasing  quantity.  In 
retention  complete  loss  of  power  of  the  muscle  may  be 
prevented  by  massage,  cool  comjpresses  and  douches,  by 
catheterization  and  by  electricity.  To  carry  out  the 
application  of  electricity  the  bladder  is  filled  with  water, 
one  pole  well  insulated  is  passed  into  the  bladder,  the 
other  pole  is  placed  upon  the  symphj'-sis  or  in  the  lumbar 
region  or  on  the  perineum,  and  the  induced  current  employed. 
To  avoid  paresis  of  the  sphincter,  which  produces  inconti- 
nence, the  exercise  of  the  will  with  tonic  treatment  and 

320 


PEOPHYLAXIS   IN   THE   DISEASES   OF   WOMEN 

hydrotlierapeutic  measures  plays  the  chief  part.  The  pres- 
ence of  calculi,  foreign  bodies  and  sacculation  of  the  bladder 
must  previously  be  excluded. 

IV.     The  Prevention  of  Injuries  and  their 
Sequelae 

{a)  Lesions  and  chcmges  produced  hy  scar  tissue. 

Lesions  of  the  generative  organs  are  caused  mostly  by 
parturition.  The  effects  vary  with  the  situation.  Healing 
by  scar  tissue  at  the  vulva  seldom  causes  atresia  ;  on  the 
contrary  gaping  is  more  commonly  produced.  The  same 
result  is  seen  at  the  os  uteri ;  lacerations  heal  by  scar 
tissue  and  eversion  is  produced.  However  in  the  vagina,  the 
vaginal  vault  and  the  cervix  we  meet  more  frequently  with 
stenosis  and  atresia. 

How  lacerations  of  the  perineum  may  be  prevented  will 
be  later  described  under  "  Obstetrics";  their  sequelae  have 
already  been  treated  of  under  "  Prolapse "  and  under 
"  Inflammations  of  the  Mucous  Membranes." 

Two  other  kinds  of  lesions  of  the  vulva  are  known : 
traumatic  lesions  and  lesions  arising  during  coitus.  Severe 
traumatic  lesions,  especially  those  near  the  clitoris,  may 
cause  serious  loss  of  blood  which  may  prove  fatal  in 
pregnancy,  and  the  bleeding  points  should  therefore  be 
ligatured.  A  tough  hymen  should  be  incised  by  a  crucial 
incision,  and  in  vaginismus  the  entrance  of  the  vagina 
should  be  forcibly  stretched  under  an  anaesthetic,  or  dilated 
by  the  passage  of  specula.  All  other  troubles  resulting 
from  perineal  lacerations,  such  as  urethritis  by  descent  of 
the  unsupported  anterior  vaginal  wall,  incontinence  of 
faeces  in  complete  lacerations  of  the  perineum,  intertrigo, 
"  garrulitas  vulvae,"  that  is  the  audible  exit  of  air  which 
has  made  its  way  into  a  gaping  vagina,  pruritus  and 
the  formation  of  rhagades  at  the  base  of  the  scar — all  may 
be  prevented  from  becoming  chronic  by  an  excision  of  the 
scar  and  by  bringing  together  the  freshened  surfaces  by 
sutures. 

Ruptures  of  the  vagina  are  the  result  of  violence :    in 

321  Y 


^rHE  PREVENTION  OE  DISEASE 

coitus,  or  according  to  tlie  author's  observations  in  vagin- 
ismus with,  cramp  of  the  muscles  of  the  fornix,  want  of  skill 
in  performing  operations,  the  introduction  of  the  hand  or 
of  pessaries  and  specula  which  are  too  large,  and  attempts 
to  procure  abortion. 

To  arrest  bleeding  the  bleeding  points  should  be 
ligatured  or  be  compressed  with  iodoform  gauze,  the 
parts  having  first  been  thoroughly  disinfected  and  all 
necrosed  shreds  removed. 

Lacerations  of  the  cervix  produce  eversion  ;  their  treat- 
ment has  already  been  given,  together  with  that  of  their 
sequelae,  under  the  heaxiing  of  "  Cervical  Catarrh."  To 
prevent  the  formation  of  fissure  ulcers  and  parametritis 
vaginal  douches  with  antiseptics  are  needed. 

Annular  and  extensive  injuries  (in  parturition  or  by 
cauterizing  or  by  ulceration)  cause  traumatic  stenosis 
and  atresia  of  the  vulva,  vagina,  or  uterus.  Preventive 
treatment  consists  partly  in  suitable  obstetric  aid,  partly 
in  maintaining  absolute  cleanliness  of  the  wounds  and 
thereby  hastening  their  healing.  If  nevertheless  contrac- 
tions set  in  they  should  be  overcome  by  stretching  with 
plugs,  or  if  there  has  been  much  loss  of  mucous  membrane 
by  a  suitable  plastic  operation  after  excision  of  the  scar 
tissue. 

If  complete  atresia  is  present  very  serious  results  may 
follow  when  pregnancy  exists  or  when  the  retained  men- 
strual fluid  produces  haematometra  and  haematosalpinx. 
In  acquired  atresia  the  menstrual  fluid,  unlike  that  in  con- 
genital atresia,  readily  undergoes  decomposition.  If  unfor- 
tunately the  haematosalpinx  is  burst  by  reflex  contraction 
while  the  incision  is  being  made  for  the  relief  of  the  atresia 
of  the  vagina  or  uterus  severe  peritonitis  is  the  immediate 
result.  The  menstrual  fluid  should  therefore  be  very  slowly 
drained  off,  and  afterwards  a  large  incision  should  be  made 
and  plugged  with  iodoform  gauze. 

(h)  The  jjrevention  of  fistulae. 

Fistulae  arise  most  often  as  the  result  of  injuries  during 
childbirth  ;  they  may  appear  at  once  as  tears  through  the 
tissues    or   they  may  appear   a   few   days  after  delivery, 

322 


PROPHYLAXIS   IN  THE  DISEASES   OF   WOMEN 

having  been  formed  by  the  sloughing  of  a  portion  of  tissue 
which  had  been  subjected  to  too  great  pressure  by  the 
foetal  head  or  injured  by  pressure  with  the  forceps.  Their 
preventive  treatment  will  be  given  under  '^  Obstetrics." 
Such  conditions  arise  in  a  generally  contracted  pelvis  with 
impaction  of  the  head  with  brow  and  face  presentations. 
It  should  be  remembered  that  vesico-vaginal  and  even 
uretero-cervical  iistulae  produced  in  parturition  tend  to 
become  spontaneousl}''  cured  by  the  drawing  together  of 
the  parts  during  involution  and  by  the  formation  of  granu- 
lations. The  introduction  of  a  self  retaining  catheter  will 
assist  this  natural  process. 

Fistulae  may  be  produced  by  ^^essaries,  especially  by 
Zwanck's  winged  pessary,  and  this  was  referred  to  in 
detail  under  "  Prolapse."  They  may  also  be  caused  by 
operations,  by  foreign  bodies  and  other  injuries,  or  by 
ulcerative  processes  which  produce  perforation,  as  seen  in 
malignant  growths,  diphtheritic  puerperal  and  venereal 
ulcers,  vesical  calculi,  perimetritic  and  parametritic  abscesses, 
haematocele,  or  extra-uterine  gestation. 

To  prevent  the  formation  of  fistulae  during  operations 
ligatures  should  not  be  too  close  together,  and  not  too  tense 
when  there  is  a  narrow  septum  between  two  hollow  organs, 
otherwise  necrosis  is  apt  to  occur.  Spaces  should  not  be 
allowed  to  remain  in  the  connective  tissue  in  which  fluid 
can  accumulate  and  pus  be  formed  producing  abscesses 
which  afterwards  break.  Adjacent  cavities  must  not  be 
opened  by  mistake  and  diverticula  or  tubes,  such  as  the 
ureters,  must  not  by  oversight  be  caught  in  the  ligatures. 

Large  bleeding  vessels  must  not  be  allowed  to  remain 
unligatured  and  so  produce  haematomata.  Foreign  bodies 
are  generally  put  into  the  vagina  for  the  purpose  of 
procuring  criminal  abortion  or  for  masturbation.  Their 
removal  often  presents  great  difficulty,  especially  as  such 
bodies  as  hairpins  are  found  even  in  the  bladder.  If 
a  parametritic  or  perimetritic  abscess  or  an  ectopic 
gestation  threatens  to  open  into  the  vagina  or  into  the 
rectum  or  bladder,  a  free  outlet  for  it  must  be  made  into 
the  vagina,  otherwise    decomposition  is  apt  to  occur  and 

323 


THE  PREVENTION  OF  DISEASE 

the  fistiilae  produced  by  the  perforation  are  more  difficult 
to  heal. 

"When  inoperable  tumours  reach  the  wall  of  the  bladder 
or  of  the  rectum  they  should  no  longer  be  treated  by 
curetting  but  only  by  the  benzene  cautery  or  by  hot 
steam,  or  a  fifty  jDer  cent,  solution  of  zinc  chloride  may  be 
applied  to  stop  decomposition  and  pain,  and  to  leave  a 
firm  fibrous  layer.  By  the  so-called  prophylactic  total 
extirpation  in  cases  of  inoperable  cancer  these  serious 
complications  are  avoided. 

(c)  The  prevention  of  traumatic  haemorrhage. 

Traumatic  haemorrhage  into  the  connective  tissue  around 
the  genitalia  produces  haematomata  ;  if  into  the  abdominal 
cavity  it  produces  intraperitoneal  haematocele.  Haema- 
toma  vulvae  is  formed  almost  exclusively  by  the  bursting 
of  a  varicose  vein  during  parturition  and  occasionally  by 
direct  violence.  The  author  saw  one  such  case  which 
reached  half  way  up  the  vagina  and  afterwards  suppurated. 

Compression  by  bandages  with  lead  lotion,  frequent  as- 
sumption of  the  recumbent  posture  and  regular  evacuation 
of  the  bowels  will  reduce  the  varicose  veins.  If  a  vein 
bursts  a  firm  pad  should  be  at  once  put  on  and  secured  by 
a  T  bandage  and  an  ice  bag  applied.  The  treatment  for  a 
sup23urating  haematoma  is  important.  If  the  skin  is  whole 
or  there  is  only  an  excoriation  or  a  fissure  applications  of 
aluminium  acetate  may  suffice.  Even  if  the  skin  threaten 
to  necrose  but  there  is  no  fever  an  attempt  may  still  be 
made  with  this  application  ;  but  as  soon  as  fever  sets  in 
an  incision  must  be  made  and  the  cavity  firmly  packed 
with  iodoform  gauze.  If  the  haematoma  of  the  vulva 
increases  in  size  in  spite  of  compression  and  use  of  the  ice 
bag,  the  physician  must  not  leave  the  patient,  because 
pressure  may  cause  the  skin  to  give  way  and  the  patient 
may  quickly  bleed  to  death.  This  risk  is  prevented  by 
immediate  incision  and  ligature  of  the  vessel,  and  the 
danger  of  suppuration  so  common  in  large  haematomata 
is  also  removed. 

Haematomata  behind,  by  the  side  of,  or  in  front  of  the 
uterus  are  most  often  caused  by  a  fall.     Slight  lesions  of 

324 


PROPHYLAXIS   IN  THE  DISEASES   OE  WOMEN 

the  uterine  ligaments  produced  by  stretching  we  have 
noticed  in  delicate  women  after  heavy  lifting  or  falling 
backwards,  and  these  are  similar  to  the  haemorrhages 
occurring  in  lesions  of  the  abdominal  muscles.  Preventive 
treatment  of  the  sequelae  should  be  directed  first  to  the 
prevention  of  further  haemorrhage  and  next  to  the  removal 
of  the  relaxation  of  the  ligamentous  apparatus  and  descent 
and  retroversion  of  the  uterus  which  have  been  left  by  the 
acute  overstrain.  In  every  case  the  patient  should  remain 
in  bed,  and  firm  plugging  is  needed  together  with  a  sand 
bag  on  the  abdomen,  and  later  a  pessary  may  be  needed. 
Colds  and  heavy  work  should  be  avoided  at  the  menstrual 
periods,  otherwise  relapse  is  very  likely  to  occur. 

When  the  haematoma  tends  to  become  inflamed,  an  ice 
bag  upon  the  abdomen  combined  with  compression  through 
the  vagina  is  useful.  If  the  haematoma  continues  to 
increase  in  size  and  there  is  danger  of  its  bursting  into 
the  abdominal  cavity,  it  may  become  necessary  to  lay  it 
open. 

Retro-uterine  intraperitoneal  liaematocele  most  often 
arises  from  the  bursting  of  a  tubal  gestation  or  from  a 
tubal  abortion.  Rarer  causes  are  a  haematosalpinx,  a 
parovarian  varicocele  which  has  burst,  haemorrhage  from  a 
Graafian  follicle,  perimetritis,  and  rupture  of  an  abdominal 
viscus  or  of  a  haematoma  of  the  broad  ligament. 

These  haemorrhages,  especially  that  caused  by  ectopic 
gestation,  may  prove  rapidly  fatal,  and  it  is  important 
therefore  to  remove  any  of  the  above  mentioned  causes 
directly  they  have  been  diagnosed. 

One  of  two  procedures  is  possible  in  the  case  of  tubal 
gestation : — 1.  During  the  first  three  months  one  or  two 
attempts  may  be  made  to  destroy  the  foetus  by  injecting 
about  a  third  of  a  grain  of  morphine  hydrochloride  into  the 
sac.  2.  The  ovum  may  be  removed  by  abdominal  section  or 
per  vaginam  if  the  sac  is  small  and  pedunculated. 

When  the  sac  is  not  pedunculated  it  is  best  to  wait  till 
the  foetus  is  dead,  otherwise  haemorrhage  is  apt  to  be 
abundant — six  months  is  the  most  favourable  time. 

If  haemorrhage  has  already  occurred  the  abdomen  should 

325 


THE  PEEVENTION  OF  DISEASE 

not  be  opened  unless,  from  the  increasing  anaemia  or  recur- 
ring collaj)se,  it  is  evident  that  haemorrhage  has  not  ceased. 
But  every  available  means  should  be  taken  to  prevent  this: 
by  ice  bag  and  sand  bags  on  the  abdomen,  rest  in  bed  with 
the  head  and  body  low  and  the  pelvis  raised  to  procure 
absorption  of  the  intraperitoneal  blood,  opiates,  saline  solu- 
tion hypodermically  and  per  rectum.  Stimulants  should  be 
given  with  caution.  Later,  when  the  clot  begins  to  sup- 
purate an  incision  should  be  made  through  the  vaginal 
wall,  and  plugs  of  itrol  gauze  or  iodoform  gauze  applied 
in  order  to  prevent  the  formation  of  chronic  abscesses 
which  might  eventually  break  through  into  the  abdominal 
cavity. 

If  the  sac  is  firmly  adherent  with  abundant  vascular 
adhesions,  as  in  abdominal  gestation,  the  sac  may  be  par- 
tially or  entirely  left,  provided  that  precautions  have  been 
taken  to  prevent  peritonitis  by  packing  with  strijDS  of 
gauze,  the  ends  of  which  should  be  brought  out  at  the 
lower  angle  of  the  wound  for  drainage,  or  by  an  extra- 
peritoneal suturing  of  the  sac  to  the  edges  of  the  wound. 
As  a  precautionary  measure  the  ovarian  vessels  and  ana- 
stomoses with  the  uterine  vessels  should  be  temporarily 
clamped.  If  it  is  decided  to  empty  a  haematocele  because 
it  threatens  to  break  through  into  the  rectum,  leading  to 
decomposition  of  the  clot,  it  is  advisable  to  remove  the  mass 
together  with  its  fibrin  capsule  as  one  would  a  tumour. 

"When  haematosalpinx  exists  there  is  the  constant 
danger  of  its  bursting  :  it  is  advisable  to  remove  it  by  an 
abdominal  section,  especially  when  there  is  a  uterus 
bicornis  with  an  imperforate  cornu  ;  because  when  the  tube 
is  tensely  filled  a  careful  examination  or  an  incision  into 
the  haematometra  from  the  vagina  may  cause  the  haema- 
tosalpinx to  burst.  The  danger  is  less  when  the  atresia  is 
lower  down.  AVhen  a  vaginal  operation  is  performed  care 
should  be  taken  to  let  the  blood  escape  slowly,  and  after- 
wards to  remove  a  large  piece  of  the  septum  to  prevent  a 
recurrence  of  the  atresia.  In  these  cases  and  in  all  cases  of 
haematocele  no  intra-uterine  manipulations  such  as  the  use 
of  the  sound  or  curette  are  permissible. 

326 


PEOPHYLAXIS   IN  THE  DISEASES   OF   WOMEN 

To  prevent  the  formation  of  indurations  after  absorption, 
use  is  made  of  mud  baths,  saline  baths,  hot  vaginal  douches, 
compression  by  plugging  and  by  a  weight  upon  the 
abdomen,  and  pledgets  of  iodine,  potassium  iodide  and 
glycerine.  During  subsequent  menstrual  periods  the 
patient  should  remain  in  bed,  as  haemorrhage  is  apt  to 
recur  at  these  times. 

The  preventive  treatment  of  the  other  causes  of  intra- 
peritoneal haemorrhage  has  already  been  described. 

(c?)  Preventive  treatment  of  foreign  bodies  in  the  genito-urinary 
organs. 

Foreign  bodies  in  these  organs  may  cause  injuries  by 
their  passage  into  the  organ,  or  may  later  cause  inflamma- 
tory changes  by  their  presence.  Preventive  treatment  for 
the  first  group  of  injuries  has  been  given  under  "  Lacera- 
tions of  the  Yulva,  Vagina,  or  Cervix." 

Foreign  bodies  may  reach  the  bladder  or  vagina  in  four 
different  ways  : 

1.  Pieces  of  surgical  instruments  may  be  left  behind, 
such  as  pieces  of  vaginal  tubes  or  glass  specula,  incrusted 
pessaries,  needles,  tampons — which  by  their  foetor  may  be 
mistaken  by  an  unobservant  physician  for  a  carcinoma — 
gauze  pledgets,  laminaria,  forgotten  silk  sutures,  and 
an  incrusted  catheter. 

2.  Through  masturbation  or  criminal  acts:  bodies  such  as 
hairpins,  tapers,  pencils  and  cotton  reels  ;  tampons,  sponges 
and  pessaries  used  to  prevent  conception  ;  knitting  needles 
and  other  ]3ointed  instruments  used  to  procure  abortion. 

3.  By  falls  upon  a  pointed  stake. 

4.  Derived  from  the  body  itself ;  as  from  perforating 
tumours,  dermoid  cysts  giving  rise  to  teeth  and  hair  ;  the 
bones  of  a  macerated  or  decomposed  foetus  from  an  extra- 
uterine gestation ;  echinococcus  vesicles ;  bodies  coming 
through  fistulae  from  other  hollow  organs.  To  this  class 
belong  vesical  calculi  and  retained  products  of  conception, 
as  in  missed  abortion  or  missed  labour. 

These  foreign  bodies  may  lead  to  inflammation,  ulceration 
or  the  formation  of  fistulge. 

For  the  prophjdaxis  of  group  1  a  few   practical   hints 

327 


THE  PRE^^NTION  OF  DISEASE 

may  be  given.  Some  opaque  glass  specula  of  a  cheap  kind, 
with  thin  walls  of  a  greyish  colour,  break  very  easily  and  in 
many  there  are  chips  and  rough  places.  The  glass  bivalve 
specula  are  dangerous.  As  to  pessaries,  all  that  is  necessary 
has  already  been  said  in  the  chapter  on  "  Prolapse."  The 
vaginal  mucous  membrane  is  particularly  prone  to  become 
excoriated  after  the  menopause.  Tampons  should  be  made 
with  a  firmly  knotted  strong  piece  of  silk,  or  a  band  long 
enough  to  hang  from  the  vulva ;  the  silk  is  tied  either 
round  the  centre  of  a  cylindrical  pledget  made  of  cotton 
wool  which  can  be  passed  into  the  vagina  crosswise,  or  in 
the  pedicled  mushroom  form  used  for  applying  medica- 
ments ;  the  silk  is  made  fast  inside  the  ball  of  the  tampon, 
the  outer  layer  of  the  ball  is  twisted  round  the  stalk  and 
the  projecting  piece  of  silk  is  then  tied  to  the  stalk.  Lam- 
in  aria  and  tupelo  tents  should  be  inserted  so  that  one 
end  of  the  tent  j)rojects  beyond  the  os  uteri,  otherwise 
they  may  become  fixed  within  the  os  and  an  incision  may 
then  be  needed  to  remove  them.  It  is  still  better  to  cover 
the  tent  with  a  piece  of  gauze  and  let  this  hang  down 
from  the  os.  A  similar  gauze  sac  passed  through  a  specu- 
lum and  filled  with  pledgets  of  cotton  wool  is  very  useful 
as  a  plug  to  produce  compression ;  the  gauze  bag  with  its 
contents  can  then  be  pulled  out  and  nothing  can  be  left 
behind  by  oversight.  Deep  silk  sutures  have  an  unpleasant 
way  of  wandering  even  after  months  or  years  into  some 
hollow  organ  (see  "  Cystitis  ").  Except  for  the  main  vessels 
(uterine  vessels),  all  ligatures  used  for  mucous  membranes 
and  for  internal  organs  should  be  made  of  well  prepared 
cymol  catgut.  For  the  skin,  nonabsorbent  ligatures  should 
be  used:  silver  wire,  silkworm  gut,  celluloid  thread,  or 
caoutchouc  silk.  Grlass  and  rubber  catheters  should  be 
examined  directly  before  and  after  use  to  see  that  they  are 
perfect. 

In  extracting  foreign  bodies  certain  precautions  must  be 
taken  to  avoid  causing  injuries  elsewhere,  which  may  be 
very  difficult  to  heal.  Grenerally  there  is  some  inflammation 
and  some  decomposition ;  the  genitalia  are  swollen  and  the 
foreign  bodies  of  such  a  shape  as  to  be  difficult  to  extract  : 

328 


PROPHYLAXIS   IN  THE   DISEASES   OF   WOMEN 

such  as  liairpins  witli  their  divergent  pointed  ends  towards 
the  vulva.  Before  the  foreign  body  is  removed,  injections, 
with  disinfectants  (lysol  is  the  best  for  this  purpose), 
should  be  used.  Long  foreign  bodies  should  be  seized  by 
one  end  and  thus  extracted.  In  some  cases  it  is  best  to 
make  more  room  by  incisions,  and  so  prevent  the  risk  of 
lacerations  and  contusions  which  might  afterwards  become 
infected.  Deep  anaesthesia  is  needed  to  produce  insensi- 
bility and  relaxation  of  the  muscles,  especially  of  the  con- 
strictor vaginae. 

In  removing  foreign  bodies  and  large  calculi  from  the 
bladder  a  cystoscope  should  be  used,  the  urethra  should  be 
dilated  sufficiently  to  admit  the  little  finger  and  a  pair  of 
dressing  forceps,  the  bladder  being  filled  with  boracic  acid 
lotion.  If  the  foreign  body  cannot  be  reduced  in  size  it  be- 
comes necessary  to  make  an  opening  into  the  bladder  from 
the  vagina,  or  to  perform  a  suprapubic  cystotomy.  Yesical 
calculi  are  seldom  found  in  women,  because  of  the  shortness 
and  width  of  the  urethra,  which  permit  concretions  as  large 
as  a  cherry  stone  to  pass.  All  foreign  bodies,  including  the 
mucus  and  pus  of  vesical  catarrh  and  of  vesical  diverticula, 
become  encased  by  deposits  of  urates,  phosphates  and  oxalates 
or  of  cystin,  and  therefore  all  causes  which  lead  to  catarrh 
of  the  bladder  and  to  retention  of  urine  should  be  speedily 
removed. 

V.  The  Prophylaxis  of  New  Growths 

From  the  aetiology  of  tumours,  which  is  still  largely 
only  speculative,  we  gather  for  purposes  of  preventive 
treatment  that  among  the  causes  which  predispose  to  the 
formation  of  tumours,  both  benign  and  maligmant,  are  long 
continued  inflammatory  processes  of  all  kinds,  chronic 
infective  diseases,  wounds  which  have  healed  by  granula- 
tion tissue  and  subsequent  formation  of  scars  at  places 
where  two  kinds  of  epithelium  meet,  chronic  congestion, 
certain  tumours  primarily  benign,  and  the  retained  pro- 
ducts of  conception.  "We  also  believe  that  further  causes 
are   to    be    found    in   the    vulnerability   of    the    genitalia 

329 


THE   PREVENTION  OF  DISEASE 

after  excessive  canterizatioii,  and  at  the  menopaiTse  when 
there  is  at  the  same  time  some  general  predisposition. 

Finally,  mention  must  be  made  of  congenital  sarcoma 
and  of  dermoids,  the  cause  of  the  origin  of  which  is  still 
obscure. 

"Whether  malignant  epithelioma  is  an  amoeba  infection 
is  still  a  contended  point.  It  should  be  remembered  too  that 
Ribbert  and  Weigert  and  recently  Lubarsch  think  that 
the  cause  of  the  increased  growth  lies  not  in  any  increased 
activity  of  the  epithelium  but  rather  in  a  diminished 
resistance  of  the  surrounding  connective  tissue,  that  is  a 
failure  to  resist  the  growth  of  the  epithelium. 

Tumours  may  also  produce  secondary  growths  in  struc- 
tures which  have  vasomotor  connexions  with  them  or  which 
are  supplied  by  the  same  vessels.  So  endometritis  fungosa 
is  associated  with  ovarian  cysts  and  with  intramural 
fibromyomata.  Of  special  interest  is  the  occurrence  of 
cancerous  growths  in  the  pedicle  of  the  uterus  after  supra- 
vaginal amputation  for  myoma  of  the  uterus. 

(a)  Benign  Tumours. 

The  formation  of  mucous  polypi  should  be  prevented  by 
early  treatment  of  the  primary  endometritis  by  curetting 
or  by  atmocausis.  Removal  of  polypi  with  the  whole  of 
the  pedicle  is  indicated  to  prevent  general  anaemia. 

Prophylactic  treatment  is  powerless  to  prevent  the  forma- 
tion of  myoma,  but  can  be  applied  to  prevent  increase  in 
size  of  the  tumour  ;  for  the  prolonged  use  of  ergot  and  the 
ligature  of  the  uterine  vessels  will  check  the  growth.  The 
same  measures  will  arrest  those  cases  of  menorrhagia  which 
last  beyond  the  climacteric  and  weaken  the  body,  often 
to  so  great  a  degree  that  it  is  not  possible  to  perform  a 
radical  operation.  Further  measures  which  can  be  adopted 
to  check  these  haemorrhages  are  hydrastis,  stypticin,  hot 
vaginal  douches  (117°  F.)  hot  fomentations,  aseptic  plug- 
ging of  the  vagina,  and  finally  intra-uterine  tampons  with 
ferripyrin  or  injections  of  solutions  of  gelatine. 

Vaginal  fibromyomata  may  cause  serious  difficulties 
during  childbirth,  and  should  therefore  be  enucleated. 
Pigmental  naevi  of  the  vulva  tend  to  undergo  malignant 

330 


PEOPHYLAXIS  IN  THE  DISEASES  OE  WOMEN 

degenerative  processes,  and  should  be  removed.  The  same 
holds  good  for  vesical  papilloma,  though  histologically 
benign,  quite  aj^art  from  the  fact  that  they  tend  also  to 
produce  haematuria,  obstruction  of  the  urethra  by  clots, 
and  vesical  catarrh  and  calculi.  A-mong  benign  tumours  of 
the  uterine  adnexa,  parovarian  cysts  which  are  large 
enough  to  reach  up  to  the  pelvic  brim  should  be  punctured, 
because  they  are  apt  to  give  rise  to  trouble.  After  punc- 
ture they  generally  remain  shrunken.  Puncture  of  ovarian 
cysts  is  useless ;  but  the  cyst  may  be  reduced  in  size,  if 
unilocular,  by  vaginal  pessaries  of  potassium  iodide  till 
symptoms  of  iodism  develop,  and  by  painting  with  iodine 
and  the  application  of  cold  water  compresses  to  the  abdo- 
men. 

(b)  Tumours  innocent  histologicaUy^  Vjhicli  under  certain 
conditions  may  become  a  source  of  danger. 

To  this  group  the  vesical  papilloma  above  mentioned  really 
belongs.  Further,  we  may  include  in  this  class  certain 
large  fibromyomata  of  the  vagina,  uterus  and  ovaries 
which  do  not  remain  stationary,  especially  the  intraparietal 
and  intraligamentous  fibromyomata  and  those  seated  upon  a 
broad  base — indeed,  all  large  new  formations  of  this  nature 
which  are  not  polypoid,  that  is  seated  upon  a  narrow  base. 
Multilocular  ovarian  cysts  also  belong  to  this  category. 

Preventive  measures  are  most  important  to  obviate  the 
dangerous  sequelae  of  fibromyomata,  among  which  are — 

1.  A  severe  form  of  anaemia,  which  is  permanent,  and 
is  caused  by  the  haemorrhages,  or  later  by  the  bursting  of 
dilated  thin  walled  vessels,  and  secondary  heart  disease. 

2.  Haemorrhages  into  the  structures  of  the  tumour  itself. 
The  cause  is  generally  a  disturbance  in  the  circulation  and 
thrombosis,  which  may  after  operation  lead  to  fatal  embol- 
ism. These  extravasations  readily  undergo  putrefactive 
changes,  and  so  give  rise  to  sepsis. 

3.  In  large  subserous  polypi  the  pedicle  may  become 
twisted,  and  produce  necrosis  and  inflammation  in  the 
tumour  and  in  submucous  polypi,  ulceration  and  gangrene. 

4.  Inflammatory  adhesions  maj^  form  between  the  tumour 
and  intestines. 

331 


THE  PEEYENTION  OE  DISEASE 

6,  Submucous  polypi  may,  as  already  mentioned,  pro- 
duce inversion  of  the  uterus,  when  tlie  polypus  is  attached 
to  the  fundus  and  numerous  strong  muscular  fibres  pass  into 
it  from  the  uterus  so  that  it  cannot  readily  break  away. 
Other  consequences  are  necrosis  by  pressure  and  gan- 
grene. 

6.  By  their  size,  especially  when  there  is  cystic  degenera- 
tion, they  may  j)roduce  symptoms  of  incarceration  and  of 
traction  upon  the  pelvic  organs,  causing  intestinal  obstruc- 
tion, uraemia,  cystitis,  and  secondary  pyelonephritis ;  or 
they  may  give  rise  to  difficulties  in  labour,  and  they  are 
then  especially  dangerous  if  calcification  has  occurred. 

7.  Myxomatous  degeneration  may  readily  go  on  to  the 
formation  of  a  myxosarcoma. 

8.  Primary  sarcomatous  degeneration  and  primary 
cancerous  degeneration  of  the  tumour  itself  or  of  the 
fungoid  endometrium  may  occur, 

9.  The  dangers  of  operative  removal  are  haemorrhage 
and  sepsis ;  and  when  removal  by  abdominal  section  is 
necessary  j)eritonitis  may  occur.  This  is  also  true  of  intra- 
ligamentous tumours  and  large  fibromata  of  the  cervix. 
Infection  may  arise  directly  or  secondarily  by  the  bursting 
of  an  abscess  which  has  formed  in  the  stump. 

Finally,  pulmonary  embolism  is  much  more  common 
than  in  the  removal  by  operation  of  other  large  tumours  of 
the  genitalia.  All  these  dangers  are  the  more  serious  the 
more  anaemic  the  23atient  already  is. 

Preventive  treatment  in  1,  2,  6,  9  must  be  directed  to 
keeping  the  tumour  small,  to  checking  haemorrhage,  and 
to  improving  the  general  health. 

The  earliest  possible  removal  of  the  tumour,  to  avoid 
complications  and  severe  anaemia,  should  be  undertaken  for 
3,  4,  5,  6,  7,  8. 

For  ovarian  cysts  there  is  no  preventive  treatment  pos- 
sible. When  a  cyst  has  attained  the  size  of  a  foetal  head 
and  continues  to  increase  in  size  it  should  be  removed.  If 
ascites  is  present  with  an  ovarian  tumour  immediate 
abdominal  section  should  be  done,  because  ascites  suggests 
malignancy. 

332 


PEOPHYLAXIS   IN  THE  DISEASES  OF  WOMEN 

(c)  Malignant  Tumours. 

Pigmented  naevi  of  the  vulva  should  be  removed,  because 
they  tend  to  undergo  malignant  degeneration,  and  the 
small  flat  red  prominences  which  may  form  with  pruritus 
of  the  vulva  should  be  removed  also.  At  the  climacteric 
any  large  or  weeping  wart  on  the  vulva  should  be  removed 
without  previous  cauterization. 

Eversion  and  erosions  on  the  vaginal  portion  of  the  cervix 
should  be  removed  either  by  cauterizing  or  by  excision. 
The  occurrence  at  the  climacteric  period  of  any  watery  or 
sanguineous  discharge  with  shreds  or  foetid  odour  should 
suggest  a  very  careful  examination  of  the  vagina,  cervix, 
and  uterine  cavity,  the  latter  with  the  curette  or  finger 
after  dilatation  of  the  os.  The  upper  part  of  the  cervix 
may  already  be  deeply  invaded  while  the  infravaginal 
cervix  and  the  external  os  show  no  sign  of  disease.  With 
the  sound  a  considerable  excavation  may  sometimes  be  de- 
tected. The  entire  uterus  and  its  adnexa  should  be  at  once 
removed  in  these  cases.  Supravaginal  amputation  of  the 
cervix  is  admissible  only  when  there  is  commencing  cancer- 
ous growth  of  the  vaginal  portion  of  the  cervix.  We  should 
remember  that  the  obstinate  endometritis  which  occurs  at 
the  climacteric,  and  is  called  fungoid,  is  generally  only  the 
commencement  of  a  carcinoma.  In  this  case  also  it  is  better 
to  operate  freely  rather  than  leave  it  until  it  is  too  late. 

Even  when  the  cancer  is  inoperable  a  palliative  extirpa- 
tion is  a  prophylactic  measure,  because  according  to  expe- 
rience the  decomposition  is  then  much  less  profuse  and 
fistulous  openings  occur  less  commonly.  The  actual  cautery 
may  be  applied  to  the  infiltrated  parts  as  it  checks  haemor- 
rhage.    Later  on  atmocausis  is  applicable. 

With  regard  to  sarcoma  it  must  be  mentioned  that  its 
cause  is  entirely  unknown,  that  fibromyomata  may  degene- 
rate into  sarcoma,  that  obstinate  multiple  flat  polypoid 
growths  are  malignant  or  readily  become  malignant,  that 
sarcomata  may  appear  even  in  early  youth,  and  that  they 
are  more  malignant  and  form  secondary  growths  sooner 
than  do  carcinomata. 

In  sarcoma  or  carcinoma  of  the  adnexa  all  measures  are 

333 


THE   PEEVENTION   OF  DISEASE 

usually  in  vain,  because  symptoms  mtake  their  appearance 
so  late.    The  most  important  symptom  is  ascites. 

VI.     Gynaecological   Operations    and 
Procedures 

Every  operation,  even  digital  examination  or  the  use  of 
the  sound,  must  be  undertaken  under  strict  aseptic  pre- 
cautions, even  when  decomposition  has  already  occurred  or 
the  patient  is  septic  or  has  gonorrhoea.  The  uterine  sound 
in  rough  and  unskilled  hands  is  a  dangerous  instrument :  to 
pass  it  through  a  stenosed  or  spasmodically  contracted  os 
uteri  may  be  difficult  and  at  times  impossible.  If  the 
uterine  walls  are  thin,  as  in  chronic  metritis  and  after 
abortion,  perforation  may  occur  though  no  sense  of  resist- 
ance has  been  felt  by  the  operator ;  the  length  of  sound 
which  has  entered  makes  him  aware  of  the  perforation.  It 
is  best  that  he  should  accept  the  fact,  and  not  attempt  to 
explain  it  away  and  proceed  with  the  operation  (curetting, 
or  washing  out  the  uterus),  for  he  would  then  be  directly 
responsible  for  the  results.  The  perforation  itself  has 
generally  no  further  consequence.  Perforation  may  occur 
during  curetting ;  this  oj^eration  should  therefore  only  be 
j)erformed  bimanually,  and  only  blunt  curettes  with  wide 
ends  should  be  used,  and  they  should  not  be  pushed  in 
and  turned  round,  but  carefully  passed  over  the  uterine 
surface.  The  larger  masses  left  behind  after  abortion 
should  be  removed  by  the  finger :  unruptured  ova  should  be 
expressed. 

Intra-uterine  irrigation  is  done  with  Fritsch's  double 
canula.  The  return  current  must  be  watched  because  the 
tube  is  liable  to  become  blocked  with  debris.  The  injection  of 
fluids,  such  as  liquor  ferri  perchloridi,  into  the  cavity  of  the 
uterus  must  be  done  carefully  during  the  slow  withdrawal 
of  a  Braun's  syringe.  The  best  way  to  do  it  is  to  fasten 
a  small  gauze  pad  on  to  the  end  of  the  syringe  tube,  which 
is  provided  with  lateral  apertures.  To  scrape  the  sacculated 
uterine  cavity  in  cases  of  submucous  myomatous  formations 
is  dangerous,  as  decomposition  readily  sets  in.     Dilatation 

334 


PROPHYLAXIS   m  THE  DISEASES   OF    WOMEN 

of  the  cervical  canal  may  be  effected  quickly  by  smooth 
conical  metal  dilators  of  increasing  size,  or  by  the  introduc- 
tion of  laminaria  or  tupelo  tents.  The  latter  should  first  be 
made  quite  smooth  and  be  sterilized  by  quickly  boiling  in  a 
five  23er  cent,  solution  of  carbolic  acid  or  by  leaving  them  for 
several  days  in  a  solution  of  iodoform  in  ether  and  alcohol. 
The  vagina  and  cervical  canal  must  previously  be  carefully 
cleansed  (see  "  Foreign  Bodies  ").  Instead  of  tents  firm 
plugging  with  iodoform  gauze  may  be  used  to  dilate  the 
cervix. 

Concerning  the  introduction  of  pessaries  prophylactic 
measures  will  be  found  in  the  chapters  on  "Prolapse  "  and  on 
'•  Foreign  Bodies."  The  prophylaxis  in  joerineoplasty  and 
colporrhaphy  will  be  found  in  the  chapters  on  "  Prolapse  " 
and  on  the  repair  of  "ruptured  perineum,"  and  in  the  Obste- 
tric section  under  suture  of  "recent  perineal  lacerations." 
Extensive  wedge-shaped  excisions  of  and  removal  of  the 
vaginal  portion  of  the  cervix  in  metritis  and  elongation  of 
the  cervix  and  annular  hypertrophy  of  the  cervix  of  a  pro- 
lapsed uterus  give  rise  to  serious  difficulties  during  child- 
birth owing  to  the  firm  scar  tissue.  In  operating  we  must 
remember  that  the  hypertrophy  is  largely  only  apjDarent, 
that  is,  it  is  produced  by  hyperaemia  and  oedema,  and 
will  disappear  when  the  uterus  is  replaced  and  still  more 
by  measures  which  produce  depletion.  For  these  reasons 
Schroeder's  excision  of  the  cervical  mucous  membrane  in 
cases  of  metritis  is  the  best  method,  because  thereby  the 
diseased  mucous  membrane  is  entirely  removed  with  its 
tendency  to  cancerous  change  and  to  eversion,  yet  the 
cervical  canal  is  not  reduced  in  diameter. 

The  prophylactic  measures  to  be  observed  in  the  more 
complex  operations  are  outside  the  scope  of  this  work. 


335 


Prophylaxis  in   Midwifery 

BY 

DE.  0.  SCHAEFFER, 

OF  THE  UNIVERSITY  OF  HEIDELBERG. 


337 


Prophylaxis  in    Midwifery 

Preventive  treatment  in  midwifery  has  botli  a  wider  and 
a  narrower  range.  For  in  the  first  place  the  development 
of  the  embryo  is  influenced  by  the  life  history  of  the  mother 
and  her  physical  constitution,  and  also  by  the  state  of 
health  of  the  father.  In  the  second  place  disease  of  the 
embryo  may  lead  to  conditions  which  are  a  source  of  danger 
to  the  mother  during  pregnancy  and  labour,  as  for  instance 
hydramnios,  hydrocephalus  and  placenta  praevia. 

Further  prophylactic  measures  may  be  adopted  even 
before  the  occurrence  of  pregnancy,  when  an  affection  of 
some  organ  or  some  constitutional  condition  exists  which 
we  know  by  experience  will  be  aggravated  if  complicated 
by  pregnancy,  such  as  tuberculosis  and  cardiac  and  renal 
disease.  In  other  cases  again  the  object  of  prophylactic 
treatment  is  to  prevent  the  establishment  of  certain  condi- 
tions during  pregnancy  labour  and  the  puerperium,  which 
will  become  a  source  of  trouble  in  later  life,  such  as 
enteroptosis. 

I.   Preventive  Treatment  during  Pregnancy 

1.  GENEEAL  MEASUEES  DUEING  PEEGNANCY 

Among  these  are  included  not  only  (1)  diet  and  hygiene 
during  pregnancy,  but  also  (2)  the  diagnosis  of  conditions 
which  may  make  delivery  at  full  term  difficult,  as  con- 
tracted pelvis,  tumours  and  vaginal  stenosis,  in  order  that 
they  may  be  removed  or  a  timely  induction  of  premature 
labour  rendered  possible ;  and  (3)  the  cure  of  existing 
diseases  which  might  lead  to  serious  consequences  during 

339 


THE  PEEVENTION  OF  DISEASE 

parturition  or   tlie  pnerperinm,  especially   uncompensated 
valvular  disease  of  the  heart  and  nephritis. 

Avoidable  causes  of  injury  to  the  embryo  are  excessive  hard 
work,  especially  heavy  lifting,  long  frequent  journeys  by 
carriage  or  by  railway  (which  cause  injury  not  only  mechanic- 
ally but  also  through  the  lumbar  centre  of  the  spinal  cord), 
violent  movements,  such  as  leaping,  and  mental  excitement. 

Among  the  forms  of  mental  excitement  which  may  be  pre- 
sent is  fear  of  the  approaching  childbirth,  and  it  may  be  re- 
moved by  reassuring  the  patient  and  by  making  necessary 
provisions  for  her  comfort,  as  by  providing  a  suitable  nurse 
or  pleasant  surroundings,  or  getting  her  admitted  into  an 
institution.  It  is  remarkable  for  example  how  very  much 
more  frequently  eclampsia  occurs  in  illegitimate  births, 
even  in  those  cases  where  the  surrounding  circumstances 
are  extremely  favourable,  and  the  co-operation  of  some 
nervous  factors  cannot  therefore  well  be  excluded.  Neu- 
rasthenic and  hysterical  women  should  be  kept  from  all 
irregularities  in  food  and  drink,  because  these  tend  to  pro- 
duce disorders  during  pregnancy  which  may  assume  very 
dangerous  proportions,  as  excessive  vomiting  and  ptyalism. 
These  patients  should  go  to  bed  earh^,  their  food  should  be 
easily  digestible,  and  no  alcohol  or  other  stimulants  should 
be  given.  Regular  action  of  the  bowels  should  be  procured 
by  diet,  mild  laxations  and  enemata.  The  care  of  the  skin, 
breasts  and  abdominal  muscles  require  daily  washing 
with  cold  or  slightly  warm  water,  but  not  too  many 
warm  baths  should  be  taken  as  they  are  often  badly  borne, 
a  bath  once  a  week  or  fortnight  would  not  be  too  fre- 
quent. The  nipples  should  be  drawn  out  from  time  to 
time  as  a  precautionary  measure. 

Besides  the  examination  of  the  heart  and  kidneys,  one 
should  examine  for  tuberculosis,  enlargement  of  the 
thyroid,  varicose  veins  and  diabetes.  "With  regard  to  the 
treatment  of  anaemia  and  chlorosis,  we  must  draw  atten- 
tion to  the  fact  that  overfeeding  is  useful  only  during  the 
first  half  of  pregnancy  and  not  during  the  last  half,  because 
it  then  only  goes  to  nourish  the  foetus  and  may  thereby 
make  delivery  more  difficult.     For  the  same  reason  it  is 

340 


PEOPHYLAXIS  IN  MIDWIFERY 

unadvisable  for  the  patient  to  take  liquids  in  large 
quantities.  In  cases  of  cardiac  disease  with,  absence  of 
compensation,  a  possible  abortion  or  fatal  syncope  during 
or  immediately  after  delivery  should  be  prevented  by  pre- 
scribing digitalis  or  strophanthus  to  restore  compensation 
as  soon  as  possible.  For  nephritis  a  diet  consisting  largely 
of  milk  should  be  given,  and  the  kidneys  should  be  relieved 
by  exciting  the  activity  of  the  skin  by  hydropathic 
measures,  such  as  warm  baths,  massage,  wet  packs  and 
diaphoretics.  For  varicose  veins  elastic  bandages  or  elastic 
stockings  should  be  worn  :  they  should  be  put  on  directly  on 
getting  up  in  the  morning.  When  there  is  much  swelling 
of  the  legs  the  patient  should  be  recommended  to  lie  down 
frequently.  Serious  enlargement  of  the  thyroid  gland 
should  be  treated  by  excision  even  during  pregnancy. 

2.    ABOETION :  ITS  PEEVENTIYE  TEEATMENT 

Abortion  occurring  before  the  fourth  month  of  pregnancy 
and  formation  of  the  placenta,  or  occurring  before  the 
viability  of  the  foetus  in  the  seventh  month,  when  it  is 
sometimes  called  miscarriage,  may  be  produced  by  four 
groups  of  causes :  (1)  General  disease  from  which  the 
mother  is  su£fering.  (2)  Accidents:  a  fall  or  blow — and 
operations.  (3)  Disease  of  the  genital  organs  or  an  un- 
developed condition  of  the  genital  organs  in  the  mother. 
(4)  Disease  of  the  foetus  and  the  membranes. 

The  general  treatment  in  threatened  abortion  should 
consist  of  rest  in  bed  and  administration  of  opiates  as 
suppositories  and  a  light  diet.  The  lower  bowel  should  be 
emptied  by  an  enema.  The  prognosis  is  bad  in  cases 
arising  from  general  disease,  but  is  generally  good  in 
cases  arising  from  accidents  or  operative  procedures,  pro- 
vided that  there  is  no  dilatation  of  the  cervix.  The  forma- 
tion of  intraplacental  haematomata  and  free  haemorrhage 
should  be  prevented  as  far  as  possible  by  opiates,  by 
lukewarm  or  cold  irrigations  with  sterilized  salt  solution, 
and  by  cold  water  abdominal  compresses.  Examinations 
and  intravaginal  treatment  must  be  conducted  with  strict 
asepsis,    that     no     infection     may     arise     if     the     ovum 

341 


THE  PEEVEiS'TION  OF  DISEASE 

later  becomes  completely  separated.  To  the  first  group 
beloDg  acute  infectious  diseases,  such  as  typhoid  fever, 
cholera,  pneumonia,  variola,  and  influenza.  These  cause 
death  of  the  foetus  by  direct  infection  or  by  the  toxines, 
or  by  the  formation  of  subchorionic  haematomata  which 
obstruct  the  circulation,  or  sometimes  by  long  continued 
pyrexia.  For  the  latter  cause  antipyretics  are  useful.  The 
elimination  of  toxines  may  be  promoted  by  dia23horesis,  by 
the  action  of  the  bowels,  and  by  injection  of  normal  saline 
solution  (-7  to  "9  per  cent.),  by  the  rectum  or  hypoder- 
mically. 

Among  the  chronic  constitutional  diseases  which  cause 
abortion  the  most  frequent  is  sj^philis.  Others  are 
diabetes,  leucaemia,  haemophilia,  scurvy  and  lastly 
eclampsia  arising  from  renal  or  hepatic  inadequacy. 
Among  organic  lesions  which  predispose  to  abortion  the 
most  important  is  cardiac  disease  with  lack  of  compensa- 
tion. Among  neuroses  the  most  important  is  chorea  and 
among  chronic  poisons  the  most  important  are  lead  and 
nicotine.  Lead  is  capable  of  causing  abortion  even  though 
present  only  in  the  father. 

Preventive  treatment  consists  in  treating  the  disease  and 
this  without  delay.  For  syphilis,  sodium  iodide  should  be 
given,  2  grains  to  15  grains  a  day ;  with  calomel  ^  grain 
to  i-  grain  three  times  a  day.  The  treatment  may  also  be 
carried  out  by  inunction.  Permission  to  marry  should  not 
be  given  till  at  least  four  years,  or  better  still  five  years, 
have  elapsed  since  the  infection,  and  three  years  since  the 
last  appearance  of  symptoms  ;  and  treatment  by  inunction 
should  be  ordered  immediately  before  marriage. 

For  the  second  group  rest  in  bed  is  the  best  treatment 
for  the  strain  upon  the  uterine  ligaments  caused  by 
accidents.  In  gunshot  wounds  of  the  uterine  wall 
premature  expulsion  of  the  embryo  always  occurs.  If  in  its 
course  the  shot  has  perforated  the  uterus  expulsion  of  the 
embryo  generally  begins  immediately,  or  the  liquor 
amnii  may  rapidly  flow  into  the  abdominal  cavity  and 
cause  the  omentum  to  float  into  the  gunshot  track  in  the 
abdominal  wall  and  so  jieritonitis  may  be  set  up.     Imme- 

3^2 


PROPHYLAXIS   IN  MIDWIFERY 

diate  abdominal  section  is  tlie  best  treatment,  and  Czerny 
has  recently  recommended  this  treatment  for  every 
jDerforating  gunshot  wound  of  the  abdomen.  If  the  ball 
lodges  in  the  uterine  wall  premature  delivery  will  ensue  in 
the  course  of  a  few  weeks,  and  it  is  not  necessary  to  per- 
form an  abdominal  section  as  a  prophylactic  measure  but 
merely  to  watch  in  case  symptoms  of  peritonitis  set  in. 

Injuries  inflicted  by  blunt  instruments  seldom  cause 
rupture  of  the  uterus,  but  produce  separation  of  the  placenta 
with  internal  haemorrhage.  The  patient  should  be  put  to 
bed  and  the  pulse  watched. 

Lacerated  wounds  of  the  abdomen  and  uterus  should  be 
treated  by  a  Mikulicz  tampon,  unless  removal  of  the  uterus 
is  indicated  because  the  tissues  have  been  injured  beyond 
possibility  of  recovery  or  because  the  wound  is  septic.    . 

Operations  should  be  performed  during  pregnancy  when 
there  is  urgent  necessity  for  them,  as  for  carcinoma  or  for 
tumours  which  will  cause  trouble  in  childbirth.  Nephrec- 
tomy, also  operations  for  appendicitis  and  for  perforations 
which  will  lead  to  peritonitis  may  be  done  when  neces- 
sary. Any  operation  may  be  performed  without  risk  to 
the  embryo,  provided  only  that  the  uterus  is  not  inter- 
fered with  ;  and  as  a  matter  of  precaution  all  interference 
with  the  uterus  should  be  strictly  avoided.  ExjDerience  has 
shown  too  that  operations  on  the  vulva,  even  incisions,  may 
induce  labour  pains.  Special  mention  must  be  made  of  the 
great  danger  arising  from  injury  to  the  vessels  of  the 
vestibule  for  fatal  haemorrhage  may  arise  from  this  cause. 

The  question  whether  further  pregnancies  should  be 
avoided  by  patients  who  have  undergone  nephrectomy 
has  been  answered  in  the  negative  by  Fritsch,  because 
pregnancy  may  run  a  normal  course  after  this  operation. 
The  prognosis  however  in  subsequent  pregnancies  de23ends 
entirely  upon  the  condition  of  the  remaining  kidney  ;  a  case 
ending  fatally  has  recently  been  reported. 

To  the  third  group  belong  endometritis  and  metritis, 
retroversion  and  retroflexion  with  descent  or  prolapse  of 
the  uterus,  and  tumours  of  the  true  pelvis.  The  latter 
should  be  pushed  ujd  into  the  false  pelvis  if  possible  ;  they 

343 


THE  PREVENTION   OE  DISEASE 

must  be  removed  if  they  are  incarcerated  or  adherent  or 
have  too  short  a  pedicle.  This  is  described  in  detail  under 
"  Tumours." 

If  conception  has  taken  place  it  is  obvious  that  no 
further  local  treatment  for  metritis  is  admissible. 

It  is  both  fortunate  and  remarkable  how  seldom  the 
inflammation  in  metritis  spreads  to  the  foetal  membranes  : 
and  it  is  only  when  it  spreads  that  abortion  will  ensue. 
Several  pathological  conditions  may  result.  Haemorrhages 
into  the  decidua  may  occur  with  the  formation  of  a 
carneous  mole ;  or  hydrorrhoea  gravidarum  caused  by 
catarrhal  endometritis  ;  decidua  polyposa,  decidua  atrophica  ; 
or  a  hydatidiform  mole,  hydramnios,  or  placentitis  with  the 
formation  of  infarcts. 

Preventive  treatment  in  these  cases  can  only  succeed  in 
warding  off  dangers  and  sequelae  which  commonly  follow 
abortion.  Strict  asepsis  should  be  observed,  decomposing 
ova  should  be  removed  as  soon  as  possible,  and  retained 
products  of  gestation  must  be  removed  digitally  or  by  the 
blunt  curette.  This  treatment  serves  at  the  same  time  to 
prevent  that  form  of  endometritis  which  is  liable  to  follow 
an  abortion,  and  to  prevent  subinvolution  of  the  uterus  and 
the  resulting  chronic  metritis.  For  the  same  reason  con- 
traction of  the  uterus  should  be  excited  by  plugging  with 
iodoform  gauze  for  twenty-four  hours,  and  then  by  the 
administration  of  ergot  and  by  hot  irrigations.  This  is 
the  best  way  of  preventing  the  habitual  abortion  which 
results  from  subinvolution  of  the  uterus  or  weakened 
innervation. 

In  cases  of  vesicular  mole  the  uterus  should  be  evacuated 
as  soon  as  possible,  and  all  fragments  left  behind  should  be 
carefully  removed  from  the  uterus  by  the  finger  or  by  a 
blunt  curette,  because  these  degenerated  villi  often  grow 
into  the  uterine  wall  and  are  apt  to  become  malignant. 
For  the  same  reason  the  patient  should  remain  under 
medical  observation  for  several  months,  and  the  process  of 
involution  of  the  uterus  or  possible  formation  of  .new 
growths  should  be  watched. 

For  hydramnios  repeated  puncture  is  sometimes  useful. 

344 


PROPHYLAXIS   IN  MIDWIFERY 

Abortion  does  not  necessarily  follow  the  puncturing  of  the 
membranes,  because  of  the  remarkable  fact  that,  in  spite  of 
the  very  great  tension  of  the  uterus,  the  bag  of  membranes 
remains  lax. 

Preventive  treatment  can  do  much  to  prevent  habitual 
abortion  in  cases  of  descent  of  the  uterus  caused  by  laxity 
of  the  ligaments.  A  pessary  should  be  worn  till  the  fifth 
or  sixth  month  of  pregnancy,  and  afterwards  an  abdominal 
belt.  The  prognosis  is  not  so  good  when  eversion  of  the 
lips  of  the  OS  exists,  whether  as  the  result  of  lacerations  of 
the  cervix  or  of  laxity  of  the  uterine  walls,  indeed  in  the 
latter  case  the  wearing  of  a  round  ring  would  according  to 
the  writer's  observation  tend  to  increase  the  eversion  of 
the  mucous  membrane. 

A  retroflexed  uterus  should  be  replaced  in  the  third 
month,  unless  spontaneous  rectification  has  already  occurred. 
It  is  still  better  to  insert  a  lever  pessary  from  the  com- 
mencement of  pregnancy. 

In  arrested  development  of  the  uterus  especially  of  the 
body  of  the  uterus,  as  in  the  infantile  form  of  uterus,  the 
tendency  to  habitual  abortion  is  successfully  treated  by 
uterine  tents  inserted  for  twelve  to  twenty-four  hours 
several  days  in  succession.  The  tents  should  be  shorter 
than  the  cavity  of  the  uterus,  and  daily  hot  vaginal  douches 
should  be  given.  The  author  has  also  found  that  a  brief 
application  of  atmocausis  for  a  quarter  of  a  minute  is  useful, 
after  the  cervix  has  been  dilated  for  forty-eight  hours  by 
tents.     In  addition  general  tonic  treatment  is  needed. 

3.    THE  INDUCTION  OF  ABORTION  AS  A  PREVENTIVE 
MEASURE  IN  AFFECTIONS  OF  OTHER  ORGANS 

An  indication  to  induce  abortion  as  a  preventive  treat- 
ment is  present  in  only  a  few  cases  of  disease.  It  must  be 
noted  that  the  exanthemata,  such  as  smallpox  and  measles, 
render  the  foetus  immune,  either  by  the  action  of  their 
toxines,  or  because  traces  of  the  infection  reach  the  foetus. 
Threatening  abortion  is  a  sign  of  the  severity  of  the  illness 
and  generally  of  bad  prognosis  for  the  mother,  so  that  the 
induction  of  premature  labour  is  of  no  use  whatever. 

345 


THE  PREVENTION  OF  DISEASE 

On  the  other  hand  vaccination  of  the  mother  during 
pregnancy  does  not  render  the  newborn  infant  immune. 
In  the  rare  febrile  Impetigo  herpetiformis  gravidarum, 
good  results  follow  the  induction  of  premature  labour, 
possibly  because  the  disease  generally  first  appears  in  the 
middle  of  pregnancy. 

Induction  of  premature  labour  cannot  be  recommended 
for  cardiac  and  pulmonary  affections  except  in  a  few 
special  cases.  The  indications  for  and  against  may  be 
formulated  thus — There  must  be  some  special  indication 
with  regard  to  the  patient  which  requires  that  premature 
labour  should  be  induced,  not  because  it  is  desirable  to 
bring  about  a  premature  delivery,  but  because  it  is  desirable 
to  end  the  pregnancy,  and  because  it  seems  probable 
that  premature  termination  of  the  pregnancy  will  be  more 
favourable  for  the  patient  than  delivery  at  full  term ;  for 
the  chief  dangers  arise  during  labour  from  its  length  and 
severity,  and  after  delivery  from  the  circulatory  changes 
which  occur  during  the  puerperium. 

The  first  object  of  preventive  treatment  in  cardiac  lesions 
must  be  to  obtain  compensatory  hypertrophy  in  the  heart, 
by  the  administration  of  strophanthus  and  digitalis,  except 
in  aortic  incompetence.  When  compensation  cannot  be  re- 
stored the  successful  issue  of  the  induction  of  abortion  will 
depend  upon  the  rapidity  of  the  expulsion  of  the  ovum  and 
upon  the  month  of  pregnancy  reached,  that  is  upon  the 
expulsive  force  required  to  complete  delivery.  The  latter  is 
indeed  less  in  premature  births,  but  on  the  other  hand  a 
premature  labour  is  apt  to  be  more  prolonged.  It  is  best  to 
puncture  the  membranes,  because  this  affords  immediate 
relief.  The  good  effect  of  the  induction  of  premature  labour 
is  seen  in  those  cases  in  which  unfavourable  symptoms 
arise,  not  from  the  shock  of  the  expulsion  of  the  embryo,  but 
rather  from  the  long  duration  of  the  strain  ujDon  the  heart 
and  circulation,  especially  in  aortic  valvular  disease.  We 
must  be  guided  too  in  our  decision  by  the  experience  that 
prolonged  strain  u]3on  the  heart  is  of  worse  prognosis  for 
those  women  who  work  hard,  for  those  in  whom  the  cardiac 
lesion  appeared  early  in  life  and  for  multiparae.     Further 

346 


PEOPHYLAXIS  IN  MIDWIFERY 

we  must  take  into  consideration  the  state  of  the  heart 
muscles,  whether  myocarditis  or  degeneration  is  present  as  a 
complication. 

Threatened  collapse  is  best  prevented  by  injections  of 
ether  and  of  camphor,  or  even  by  venesection;  ether  is 
useful  even  for  anaesthesia.  The  treatment  directly  after 
the  expulsion  of  the  foetus  is  important ;  a  sand  bag  should 
be  placed  upon  the  abdomen  to  prevent  sudden  collapse  by 
the  reduction  of  blood  pressure  in  the  abdominal  cavity, 
and  ether  should  be  given,  but  never  ergot.  Post  partum 
haemorrhage  is  of  less  serious  import  than  usual,  because  it 
relieves  the  heart. 

Seeing  that  the  induction  of  premature  labour  is  under- 
taken under  such  very  unfavourable  conditions,  it  is  best  to 
explain  to  the  relatives  what  are  the  risks  and  the  gravity 
of  the  prognosis.  In  forming  a  prognosis  we  must  take 
into  consideration  too  any  complications  which  may  exist, 
whether  renal,  gastric,  intestinal  or  hepatic,  because 
the  retention  of  toxins  resulting  from  disease  of  these 
organs  acts  as  an  additional  burden  upon  the  heart. 

Even  without  these  latter  complications  we  find,  as  has 
been  mentioned  above,  that  degeneration  of  the  heart  muscle, 
early  appearance  of  the  cardiac  lesion,  and  serious  failure  in 
cardiac  compensation  render  the  prognosis  much  more  un- 
favourable, especially  in  weakly  and  very  anaemic  patients 
and  in  cases  where  the  conditions  of  life  do  not  permit 
of  the  necessary  care  being  taken.  Medical  consent 
to  marry  should  not  be  given  to  girls  so  affected.  The 
number  of  pregnancies  in  such  cases  should  not  exceed 
two. 

In  pulmonary  affections,  especially  in  phthisis,  the 
effects  of  parturition  are  not  less  serious  ;  those  are  the  loss 
of  blood,  the  muscular  exertion,  and  a  tendency  to  cardiac 
inadequacy  with  consequent  oedema  of  the  lungs.  For 
these  reasons  the  induction  of  premature  labour  should  not 
be  undertaken,  though  artificial  abortion  may  be  advisable 
in  cases  where  it  appears  probable  that  the  end  of  pregnancy 
will  not  be  reached  or  will  be  reached  under  very  serious 
conditions.     In  these  cases  of  chronic  organic  disease  the 

347 


THE   PREVENTION  OF  DISEASE 

question  may  arise  wlietlier  it  is  justifiable  to  produce 
sterility  in  tlie  woman  by  obliteration  of  tlie  uterine  cavity 
by  repeated  application  of  steam,  or  by  removal  of  the 
ovaries,  or  by  excising  the  Fallopian  tubes  and  closing  the 
uterine  apertures. 

Similar  indications  will  guide  us  in  deciding  upon  the 
induction  of  abortion  prophylactically  in  diseases  of 
metabolism  and  nervous  affections  caused  by  retention  of 
the  toxins  of  metabolism,  that  is  by  auto-intoxication. 
The  most  serious  and  most  common  of  these  affections  are 
excessive  vomiting  at  the  beginning  of  pregnancy  and 
eclampsia  towards  the  end  of  pregnancy.  Others  are  ptyal- 
ism,  uncontrollable  diarrhoea,  icterus  gravidarum,  diabetes, 
haemophilia,  scurvy,  exophthalmic  goitre,  many  forms  of 
neuritis,  and  a  severe  form  of  chorea,  which  has  a  mortality 
of  thirty  per  cent,  and  premature  delivery  in  twenty  per 
cent,  of  the  cases.  Epilepsy,  hysteria,  tetany,  myelitis 
and  various  psychoses  may  also  occur.  The  general 
prophylaxis  for  all  these  disorders  consists  in  suitable 
hydropathic  treatment  and  in  imi^roving  the  general 
health.  It  is  more  important  still  that  this  plan  of  treatment 
should  be  followed  when  pregnancy  has  occurred,  especially 
for  the  reflex  neuroses  which  are  associated  with  hysteria. 

For  excessive  vomiting  in  mild  cases,  increase  of  its 
severity  may  be  prevented  by  a  light  or  fluid  diet,  though 
milk  is  unfortunately  often  badly  tolerated  even  with  the 
addition  of  lime  water,  or  when  boiled  with  starch  flour. 
A  strong  exercise  of  the  will  and  determination  not  to 
yield  to  the  inclination  to  vomit  is  also  of  great  value.  A 
cautious  examination  of  the  generative  organs  should  be 
made  to  determine  whether  retroflexion  of  the  incarcerated 
gravid  uterus  is  present  or  some  anomaly  of  the  ovum, 
such  as  vesicular  mole,  missed  abortion  or  hydramnios. 

In  these  cases  puncture  of  the  membranes  and  dilata- 
tion of  the  cervix  are  often  of  use  in  addition  to  a  pessary, 
and  are  not  followed  by  abortion.  Vomiting  caused  by 
dyspepsia  is  best  treated  with  orexin  5  grains  to  8  grains 
in  capsules  two  or  three  times  a  day.  In  the  severer  forms 
of    uncontrollable  vomiting,   the  stomach    must   be  given 

348 


PROPHYLAXIS  IN   MIDWIFERY 

complete  rest  to  prevent  serious  consequences,  or  even 
fatal  results,  Nourishment  must  be  given  entirely  per 
rectum  ;  at  first  normal  saline  solution,  tlien  oatmeal  water, 
then  white  of  egg  in  water,  and  lastly  nutrient  enemata  of 
milk,  egg,  butter  and  sugar.  The  author  has  found  alkar- 
nose  enemata  very  satisfactory.  Sometimes  enemata  may 
at  first  cause  retching  and  bilious  vomiting.  In  patients 
who  have  become  much  emaciated  the  action  of  the  heart 
may  be  so  seriously  impaired  by  deficiency  of  fluid  in  the 
body  and  by  an  overloading  of  the  tissues  with  toxines, 
that  it  becomes  necessary  to  have  recourse  to  hypodermic 
or  to  intravenous  injections  of  sterilized  normal  saline 
solution. 

But  these  are  the  cases  for  which  induction  of  abortion  is 
the  right  treatment  and  is  successful  if  not  done  too  late. 
The  condition  of  the  pulse  is  the  best  guide,  for  death  has 
occurred  even  after  spontaneous  or  artificial  abortion  when 
weakness  of  the  heart's  action  is  too  far  advanced. 

The  same  holds  good  for  uncontrollable  ptyalism  and 
diarrhoea,  which  reduce  the  patient's  strength  by  loss  of 
sleep  and  loss  of  albuminous  fluids.  For  both  these  dis- 
orders treatment  consists  in  stimulating  the  action  of  the 
skin  by  hydrotherapy  and  in  promoting  diaphoresis  and 
diuresis,  but  if  these  are  unsuccessful  nothing  can  be  done 
except  induction  of  abortion. 

In  all  these  cases  the  use  of  narcotics  is  strictly  contra- 
indicated. 

For  chorea  with  very  severe  symptoms,  especially  with 
insomnia,  induction  of  abortion  offers  the  only  chance  of 
saving  life.  In  leukaemia  and  in  pernicious  anaemia  an 
improvement  in  the  patient's  general  condition  has  followed 
the  induction  of  abortion.  In  very  bad  cases  of  exophthal- 
mic goitre  abortion  occurs  spontaneously ;  if  it  does  not 
occur  the  prognosis  is  good. 

Artificial  abortion  is  strictly  contra-indicated  in  all 
diseases  of  the  blood,  and  treatment  consists  in  injections  of 
20  cubic  centimetres  of  a  2  per  cent,  gelatine  emulsion, 
or  of  a  10  to  20  per  cent,  emulsion  per  rectum.  Calcium 
hypophosphite  may  be  given  to  the  extent  of  2  drams  per 

349 


THE  PREVENTION  OF  DISEASE 

day  by  mouth,  or  3  drains  per  rectum.  Sodium  iodide  may 
also  be  prescribed. 

Diabetes  is  considerably  aggravated  by  pregnancy,  and 
tends  to  premature  expulsion  of  tlie  ovum  during  tbe  latter 
ball  of  pregnancy.  It  should  first  be  treated  by  dieting 
and  by  regularity  of  living.  The  induction  of  premature 
labour  is  indicated  in  those  cases  only  where  it  is  impossible 
to  reduce  the  excessive  excretion  of  sugar,  and  where  there 
is  rapid  deterioration  in  the  general  condition  of  the 
patient ;  but  such  cases  are  extremely  rare.  The  embryos 
are  often  of  low  vitality.  Women  who  have  diabetes  should 
not  marry. 

In  renal  disease,  with  a  tendency  to  eclampsia  towards 
the  end  of  gestation,  or  with  retinitis  albuminurica,  much 
may  be  done  during  pregnancy  to  relieve  the  kidneys 
which  are  affected  by  Bright's  disease.  The  patient  should 
be  treated  by  hydropathic  '"iDacking,"  and  not  by  the  in- 
duction of  premature  labour.  But  when  serious  symptoms 
arise  which  threaten  life,  such  as  an  extreme  degree  of 
dropsy  and  retinitis,  with  vision  less  than  one-sixth,  it 
becomes  necessary  to  consider  the  advisability  of  inducing 
premature  labour  as  a  preventive  measure.  But  it  must  be 
remembered  that  measures  intended  to  excite  labour  pains 
will  also  reflexly  excite  attacks  of  eclampsia,  or  if  eclampsia 
has  already  appeared  will  increase  the  fits  to  a  dangerous 
extent.  Preventive  treatment  for  eclampsia  consists  in 
elimination  of  the  toxines  from  the  blood  as  speedily  as 
possible,  and  in  relieving  the  kidneys  and  cerebral  con- 
gestion by  exciting  diaphoresis  by  baths  and  by  wet 
packs.  The  eclamptic  convulsions  may  be  checked  by 
chloralhydrate  or  morphia,  and  by  the  avoidance  of  every- 
thing that  tends  reflexly  to  produce  them,  such  as  noises  in 
the  room,  vaginal  examinations  and  futile  attemjjts  to 
bring  about  delivery.  For  all  obstetric  procedures  the 
patient  should  be  under  the  influence  of  chloroform. 

Thus  in  the  preventive  treatment  of  general  diseases,  and 
of  disease  of  organs  other  than  the  generative,  the  indica- 
tions for  the  induction  of  abortion  or  of  premature  labour 
depend    entirely    on    the    individual    case,    and    are    not 

350 


PROPHYLAXIS  IN  MIDWIFERY 

sharply  defined  or  absolute.  In  the  preventive  treatment 
of  anomalies  of  the  pelvis  and  of  the  generative  organs 
however  the  indications  for  the  induction  of  abortion  are 
definite  and  exact. 

A.  Indications  for  the  induction  of  abortion  up  to  the 
fourth  month  : 

(a)  Great  pelvic  contraction,  the  shortest  diameter  being 
2  inches  or  less,  where  a  viable  child  of  thirty -four  weeks 
could  not  be  delivered  ;  and  a  mature  child  could  not  be 
delivered  by  craniotomy. 

(&)  The  presence  in  the  true  pelvis  of  a  tumour  which 
cannot  be  removed  or  reduced  in  size  or  pushed  out  of  the 
pelvis.  This  indication  is  rarely  present  except  in  carci- 
noma of  the  uterus. 

(c)  Displacement  of  the  uterus  which  cannot  be  reduced, 
especially  retroflexion  caused  by  adhesions,  or  with  sup- 
puration. 

(d)  Hydatidiform  mole. 

B.  Indications  for  the  induction  of  premature  labour  if 
possible  not  till  after  the  thirty-fourth  week : 

{a)  Pelvic  contraction,  according  to  the  following  rules  : 
In  the  thirty-fifth  week  when  the  true  conjugate  is  slightly 
over  3  inches,  or  in  generally  contracted  pelves  even  when 
the  conjugate  is  3|  inches,  or  in  infundibular  pelves  when 
the  transverse  diameter  at  the  outlet  is  3  inches. 

In  the  thirty-third  to  the  thirty-fourth  week,  for  a  true 
conjugate  of  3  inches,  with  2|  to  3  inches  between  the 
tuberosities  in  an  infundibular  pelvis. 

In  thirty-first  to  thirty-third  week  for  a  true  conjugate 
of  2f  to  3  inches. 

Before  the  thirtieth  week  for  a  true  conjugate  of  21  to 
2f  inches. 

"With  a  true  conjugate  of  2^-  inches  the  induction  of 
abortion  is  generally  required. 

With  regard  to  further  preventive  treatment,  it  must 
be  mentioned  that  by  a  suitable  diet  consistently  and 
regularly  followed,  children  decidedly  thinner  than  usual 
are  in  many  cases  brought  into  the  world.  The  food  should 
be  such  as  does  not  form  much  fat  or  much  liquid.     If  any 

351 


THE  PREVENTION   OF  DISEASE 

good    is    to   be   attained   from   tliis   method,    it   must    be 
employed  sufficiently  early. 

(}))  Placenta  praevia  with,  serious  haemorrhages. 

(c)  Habitnal  death  of  the  foetus  at  a  certain  time. 

(d)  Hydramnios  with  great  danger  to  the  mother  when 
it  obstructs  the  diaphragm  and  causes  great  disturbance  of 
the  circulation. 

4.    PREVENTIVE  TREATMENT  FOR  ANOMALIES  OF  FORM 
AND  OF  POSITION  OF   THE  UTERUS  DURING  PREGNANCY 

Want  of  space  and  circulatory  disturbances  may  in  these 
cases  lead  to  spontaneous  abortion,  or  more  frequently  to 
premature  delivery,  and  in  very  rare  cases  may  make  it 
necessary  to  induce  labour. 

(a)  The  dangers  arising  out  of  anomalies  of  development 
are  on  the  one  hand  laceration  of  the  distended  uterine 
cornu  in  uterus  unicornis  and  bicornis,  and  in  uterus 
didelphys  ;  and  on  the  other  hand  obstruction  of  the  pelvis 
by  the  other  cornu.  The  question  of  the  preventive  treat- 
ment depends  upon  our  diagnosis  of  the  case,  and  unfortu- 
nately there  is  very  little  experience  to  guide  us. 

The  preventive  treatment  for  pregnancy  in  a  rudimen- 
tary uterine  cornu  with  atresia  is  the  same  as  that  for 
extra-uterine  gestation ;  the  results  of  both  conditions  are 
the  same. 

(&)  In  retroflexion  of  the  gravid  uterus  the  uterus  must 
first  be  replaced  and  then  kept  anteflexed  by  a  lever 
pessary  from  the  first  to  the  fifth  month,  which  should 
be  taken  out  occasionally  and  then  reinserted.  By  this 
treatment  we  prevent  incarceration  of  the  uterus  with  its 
serious  consequences.  Among  these  are  abortion,  severe 
reflex  phenomena,  such  as  uncontrollable  vomiting  and 
ptyalism,  difficulty  in  micturition,  with  subsequent  gan- 
grene of  the  bladder,  and  lastly  rupture  of  the  bladder. 

The  bladder  and  the  bowel  must  be  emptied  before  any 
attempt  is  made  to  replace  the  uterus.  The  attempt  often 
fails,  and  it  then  becomes  necessary  to  draw  down  the 
cervix  by  vulsellum  forceps,  and  to  push  up  the  body 
of  the   uterus  by  pressure,   either   through   the   posterior 

352 


PROPHYLAXIS  IN   MIDWIFERY 

vagiual  vault  or  through  the  rectum,  or  finally  by  the 
hand  on  the  abdomen.  This  can  be  done  most  easily 
when  the  patient  stands  upright,  or  is  placed  so  that 
the  pelvis  is  raised — that  is,  the  knee-elbow  position. 
There  is  often  difficulty  and  danger  in  passing  the 
catheter,  and  sometimes  it  becomes  impossible  till  the 
vaginal  part  of  the  uterus  has  been  lifted  and  pushed  away 
from  the  symphysis.  In  other  cases  all  attempts  are  in 
vain,  and  to  use  force  is  always  dangerous.  For  these 
cases  we  use  the  slow  steady  pressure  exerted  by  Meyer's 
elastic  ring  pessary  or  by  a  dilatable  vaginal  bag.  Sims' 
lateral  position,  or  the  knee-elbow  position,  is  best  for  this 
purpose,  "While  filling  the  dilatable  vaginal  bag  with 
sterilized  fluid,  care  must  be  taken  not  to  make  the  bag  too 
tense,  as  lacerations  of  the  vagina  have  been  produced  in 
this  way. 

"When  all  efforts  to  introduce  a  catheter  have  failed,  as 
force  must  not  be  used  lest  the  bladder  should  burst,  it 
must  be  punctured  through  the  vagina,  so  that  the  urine 
may  not  infiltrate  the  connective  tissue  around  the  bladder, 
or  the  bag  of  membranes  may  be  punctured  through  the 
posterior  vaginal  vault.  If  the  cervix  and  the  cervical 
canal  are  within  reach,  and  the  canal  is  patent,  it  is  best  in 
these  cases  to  induce  abortion  by  passing  a  bougie,  and  by 
plugging  with  gauze  soaked  in  glycerine.  The  uterus 
may  be  rapidly  emptied  of  the  contained  ovum  by  an 
incision  into  it  made  through  the  posterior  vaginal  vault. 
On  the  other  hand  abortion  may  be  prevented  by  replacing 
the  uterus  from  above,  that  is  by  an  incision  through  the 
abdominal  wall. 

(c)  Descent  and  prolapse  of  the  uterus  readily  lead  to 
abortion.  It  may  be  prevented  by  the  use  of  a  pessary  till 
the  fifth  month.  Plastic  operations,  such  as  colporrhaphy, 
perineorrhaphy,  are  also  practicable,  and  are  especially 
useful  when  excoriations  of  the  os  uteri  are  combined 
with  prolapse,  because  in  case  of  spontaneous  abortion  such 
excoriations  readily  become  infected,  and  may  lead  to 
serious  consequences. 

The  best  preventive  treatment  in  all  case  of  anomalies 

353  A  A 


THE  PREVENTION  OF  DISEASE 

of  position    is  their   rectification   before    conception   takes 
place. 

{d)  There  are  several  varieties  of  anteflexion  whicli  give 
rise  to  symptoms  in  pregnancy,  some  of  which,  are  very 
troublesome  and  serious.  One  form  is  infantile  anteflexion, 
which  predisposes  to  abortion,  and  is  often  associated  in 
primiparae  with  excessive  vomiting,  according  to  the 
author's  observations.  Other  anteflexions  occur  in  conse- 
quence of  lax  ligaments  and  of  a  lax  abdominal  wall,  and 
in  flattened  pelvis,  which  causes  a  pendulous  abdomen. 
Lastly  anteflexion  may  be  caused  by  vaginal  or  vesical 
fixation,  or  more  rarely  by  ventrifixation ;  these  fixations, 
as  well  as  those  produced  in  other  ways,  may  lead  to  the 
formation  of  pouches  in  the  uterus.  Abortion  is  frequent 
in  cases  of  antefixation.  The  induction  of  abortion  is 
indicated  when  the  embryo  in  its  development  causes  over- 
stretching and  great  tension  of  the  posterior  uterine  wall, 
and  when  at  the  same  time  the  vaginal  portion  of  the 
cervix  is  pulled  backwards. 

The  best  preventive  treatment  is  to  avoid  hysteropexies 
during  the  years  when  childbearing  is  possible,  for  they 
are  capable  of  producing  these  uncontrollable  adhesions. 

A  pendulous  abdomen  should  be  supported  by  means  of  a 
strong  wide  belt  which  fits  the  convex  form  of  the  abdomen. 
This  will  prevent  overstretching  of  the  abdominal  fasciae 
and  separation  of  the  recti,  and  thus  from  the  very  first  will 
prevent  a  faulty  position  and  faulty  presentation  of  the 
embryo.  Hydramnios  and  twin  pregnancies  also  predis- 
pose to  this  condition. 

Laxity  of  the  ligaments  combined  with  rickety  pelvis, 
and  also  infantile  anteflexion  of  the  uterus  are  found  in 
hysterical,  neurasthenic  and  chlorotic  young  women.  Pre- 
ventive treatment  should  be  early  begun  to  remove  these 
conditions  of  weakness. 

(e)  For  the  rare  cases  in  which  the  pregnant  uterus  is 
found  in  a  hernia,  ventral,  inguinal  or  femoral,  preventive 
treatment  consists  in  reduction,  or  in  artificial  abortion,  or 
in  herniotomy  and  removal  of  the  uterus  or  uterine  horn. 
The  best  treatment  of  all  is  for  the  patient  to  wear  a  strong 

354 


PROPHYLAXIS  IN  MIDWIFERY 

truss  before  pregnancy  occurs  or   to  have   a  radical  cure 
performed. 

5.  PREVENTIVE  TREATMENT  FOR  TUMOURS  OF  THE 
GENERATIVE  ORGANS  IN  PREGNANCY 

Tumours  may  interfere  with  pregnancy  by  obstructing 
the  true  pelvis.  The  tumours  may  be  derived  from  pelvic 
organs  or  may  have  come  down  through  the  pelvic  brim, 
as  for  instance  a  floating  kidney  or  a  hydronephrosis. 

(a)  For  fibromyomata  great  experience  is  required  in 
deciding  what  is  the  right  treatment  for  any  given  case. 
The  following  questions  must  first  be  answered  :  "  Have 
serious  symptoms  already  appeared  during  the  pregnancy  ?  " 
"Do  we  think  that  such  symptoms  will  appear  before  the 
time  when  the  child  is  viable?  "  "  Will  labour  at  full  term 
cause  dangerous  conditions  which  it  will  be  very  difficult 
or  even  impossible  to  overcome,  and  thus  endanger  the  lives 
both  of  mother  and  child? "  "  Is  the  immediate  removal  of 
the  tumour  less  dangerous  than  if  longer  delayed?  and 
must  the  ovum  be  removed  at  the  same  time?  or  will  it 
suffice  to  induce  premature  labour  ?  " 

The  answers  depend  upon  the  situation  and  size  of  the 
tumour. 

The  dangers  in  so  far  as  the  embryo  is  concerned  are 
many.  First,  conception  is  difficult  or  impossible  because 
of  the  presence  of  large  or  polypoid  fibromata,  or  because  of 
the  resulting  changes  in  the  endometrium.  Next,  abortion 
may  occur  with  possible  retention  of  parts  of  the  ovum  and 
decomposition.  Other  possible  results  are  malformations  of 
the  foetus  through  want  of  sufficient  space,  placenta  praevia 
or  even  tubal  gestation. 

The  dangers  during  pregnancy  which  arise  from  the 
tumour  are  incarceration  of  the  tumour  under  the  pro- 
montory of  the  sacrum ;  or  torsion  of  its  pedicle,  followed  by 
strangulation,  which  may  also  be  produced  by  disturbances 
of  the  circulation  and  haemorrhages  when  there  is  a  ten- 
dency to  thrombosis  of  the  veins  of  the  uterine  appendages. 
A  further  danger  is  a  marked  increase  in  size  of  the  tumour 
owing  to  oedema  and  to  fibrous  growth.     Even  when  the 

355 


THE  PREVENTION  OF  DISEASE 

shape  and  situation  of  the  tumour  are  such  that  it  will  not 
cause  difficulty  during  labour,  central  hsemorrhages  and 
softening  readily  occur,  and  may  give  rise  to  sepsis. 

Experience  has  shown  that  we  should  be  guided  by  the 
following  rules  for  treating  tumours  : 

Small  fibroids  of  the  body  of  the  uterus  should  be  left  un- 
touched. Cervical  polypi  should  be  removed  at  once  in  the 
simplest  and  most  careful  way  possible.  If  the  fibroids  are 
upon  a  broad  base  in  the  cervical  wall,  they  should  be  left 
till  the  time  of  childbirth ;  and  the  same  holds  good  for 
submucous  fibroids. 

With  large  cervical  fibromyomata  which  obstruct  the 
passage  we  have  to  consider  whether  it  is  possible  either 
now  or  later  to  push  the  tumour  out  of  the  waj^  or  to  remove 
it ;  and  here  our  knowledge  both  of  the  increase  in  size  and 
of  the  change  in  form  of  myomata  from  the  effect  of  labour 
pains  is  of  value.  Labour  pains  have  often  easily  accom- 
plished what  energetic  efforts  to  push  the  tumour  out  of 
the  way  have  failed  to  do  under  an  anaesthetic.  No  attempt 
should  be  made  to  alter  the  position  of  the  tumour  before 
the  eighth  month  for  fear  of  producing  abortion,  except 
when  there  are  symptoms  of  incarceration.  If  the  tumour 
cannot  be  pushed  out  of  the  way  it  must  be  removed  by 
abdominal  section. 

The  same  considerations,  as  to  the  possibility  of  altering 
the  position  of  the  tumour,  apply  to  subserous  fibroids 
which  become  fixed  in  the  pehds  beneath  the  j^regnant 
uterus.  In  some  cases  the  induction  of  premature  labour 
is  indicated,  according  to  the  rules  already  given  for  the 
induction  of  labour  in  contracted  pelves. 

After  such  induction  of  labour  and  after  spontaneous 
abortion  all  retained  products  of  conception  should  at  once 
be  removed  to  prevent  sepsis.  If  septic  infection  is  already 
present,  the  uterus  and  tumour  should  be  removed  without 
delay  to  prevent  a  general  septic  infection. 

Removal  of  the  fibroid  by  abdominal  section  is  best 
undertaken  at  the  end  of  pregnancy,  and  may  then  be 
looked  upon  as  a  curative  and  not  as  a  preventive  procedure. 
It  is  a  preventive  measure  only  when  performed  for  some 

356 


PROPHYLAXIS  IN  MIDWIFERY 

threatening  danger,  such  as  torsion  of  the  pedicle  or  irre- 
ducible incarceration,  decomposition,  or  when  the  fibroid  is 
complicated  with  disease  of  some  other  organ,  especially 
cardiac,  pulmonary  or  renal  affections,  so  commonly  seen  m 
patients  with  myomata.  In  many  cases,  as  when  the 
tumour  is  already  infected,  total  extirpation  is  advisable. 

(&)  Ovarian  tumours  should  generally  be  removed  during 
pregnancy  without  further  consideration,  and  this  is  best 
done  during  the  early  months  :  even  double  ovariotomies 
very  seldom  cause  abortion.  The  induction  of  abortion 
instead  of  removal  of  the  tumour  is  not  indicated,  except 
when  the  tumour  is  generally  adherent  in  Douglas'  pouch, 
or  is  situated  within  the  folds  of  the  broad  ligament. 

Ovariotomy  should  be  performed  when  certain  dangers 
in  pregnancy  have  arisen  or  are  anticipated.  These  dangers 
do  not  arise  from  an  increase  in  size,  as  is  the  case  with 
myomata,  but  from  circulatory  disturbances,  such  as  hsema- 
tomata  and  thromboses,  ]3roduced  by  the  uterus  as  it  rises 
in  the  abdomen  and  drags  upon  the  pedicle.  A  further 
danger  is  torsion  of  the  pedicle,  resulting  in  necrosis  of  the 
tumours,  which  affords  a  locus  minoris  resistentiae  for  infec- 
tion, or  which  may  give  way  if  there  is  softening  of  the 
wall.  The  danger  with  small  tumours  is  that  they  may 
become  fixed  beneath  the  promontory  of  the  sacrum,  and 
fibromata  which  cannot  be  punctured  may  completely 
obstruct  the  pelvis.  Incarceration  of  the  retroflexed  uterus, 
followed  by  abortion  or  by  prolapse  of  the  uterus,  is  pro- 
duced by  large  tumours  which  obstruct  the  pelvic  brim. 

(c)  The  preventive  treatment  in  carcinoma  of  the  uterus 
consists  in :  (1)  For  operable  cases,  the  whole  uterus  should 
at  once  be  removed.  During  the  latter  half  of  pregnancy, 
before  the  viability  of  the  foetus,  this  should  be  done  after 
previously  removing  the  ovum  by  an  anterior  vagino- 
cervical  incision.  From  the  thirty-second  week  onwards, 
by  induction  of  premature  birth  by  deep  incisions  in  the 
cervical  wall  and  vaginal  extirpation  of  the  uterus  ;  but  if 
the  cervical  canal  cannot  be  sufficiently  dilated,  the  foetus 
must  be  delivered  bj^  Caesarian  section,  and  then  the  body 
of  the  uterus  be  amputated  by  the  supravaginal  operation, 

357 


THE   PEEVENTION   OF  DISEASE 

while  the  cancerous  cervix  is  removed  per  vaginam.  (2)  In 
inoperable  cases  the  utmost  must  be  done  to  preserve  the 
life  of  the  mother,  and  so  save  the  child.  Palliative 
measures  should  be  used  to  check  growth  and  decompo- 
sition, as  by  the  use  of  the  thermocautery,  atmocausis,  or 
cauterizing  with  chloride  of  zinc, 

"When  it  is  desired  to  induce  premature  labour,  and  the 
cervical  canal  is  impassable  through  the  presence  of  an 
inoperable  malignant  mass,  Caesarian  section  must  be  per- 
formed, and  then  as  a  preventive  measure  supravaginal 
hysterectomy  should  be  performed  to  prevent  infection. 

6.    PREVENTIVE  TREATMENT  OF   EXTRA-UTERINE 
GESTATION 

To  prevent  extra-uterine  gestation  the  causes  which 
most  frequently  lead  to  it  should  be  removed.  Amongst 
these  are  all  forms  of  inflammation  of  the  generati^^e  organs  ; 
gonorrhoea!  inflammations,  which  may  cause  or  have  already 
produced  salpingitis,  tuberculous  salpingitis  and  jDeri- 
oophoritis,  as  well  as  all  pelvic  congestions. 

When  a  diagnosis  of  ectopic  (generally  tubal;  gestation 
has  been  made,  definite  prophylactic  measures  should  be 
taken  to  prevent  serious  consequences. 

The  most  favourable  course  relatively  is  the  bursting  of 
the  embryo  sac  during  the  first  two  months,  followed  by 
absorption  of  the  retro-uterine  hsematocele  so  formed  and 
of  the  ovum.  In  the  later  months  fatal  haemorrhages  and 
decomposition  of  the  embr^^o  readily  set  in.  There  is  not 
complete  unanimit}^  as  to  the  treatment  which  should  be 
adopted. 

1.  During  the  first  three  months  injections  of  one-third 
grain  of  morphia  may  be  made  into  the  embryo  sac  on  two 
occasions,  without  aspiration  of  the  liquor  amnii,  and  with 
strict  aseptic  precautions,  to  kill  the  embryo. 

2.  If  the  ovum  continues  to  grow  in  spite  of  this  treat- 
ment, or  if,  especially  in  obscure  cases,  the  symptoms  are 
serious  and  urgent,  the  embrj^'O  sac  should  be  removed  bj- 
abdominal  section,  or  if  it  is  distinctly  pedunculated,  mov- 
able and  small  it  may  be  removed  jjer  vaginam. 

358 


PROPHYLAXIS  IN  MIDWIFERY 

3.  Ill  rare  cases  when  the  foetus  is  still  alive  and  has 
reached  the  thirty-second  week,  abdominal  section  should 
generally  be  performed  in  order  to  remove  as  far  as  possible 
the  dangers  with  which  the  mother  is  threatened.  In 
exceptional  cases  when  the  mother  urgently  desires  it  for 
the  child's  sake,  one  may  wait  till  the  thirty-fifth  week, 
and  then  deliver  the  patient  by  abdominal  section.  In 
these  cases  all  possible  precautionary  measures  should  be 
taken  to  prevent  bursting  of  the  embryo  sac ;  the  patient 
should  be  kept  in  bed,  opiates  given,  and  if  serious  symptoms 
appear  we  must  at  once  proceed  to  open  the  abdomen.  It 
is  best  that  the  patient  should  be  in  a  hospital. 

4.  If  the  rupture  of  the  sac  has  occurred  the  abdomen 
must  be  opened  and  the  bleeding  vessels  ligatured  to 
prevent  a  fatal  result  from  the  continuance  of  intraperitoneal 
haemorrhage,  but  this  is  only  practicable  when  a  few  hours 
have  elapsed  and  collapse  is  not  too  severe. 

5.  When  an  intraperitoneal  haematocele  has  formed  and 
there  are  no  symptoms  of  further  internal  haemorrhage, 
measures  should  be  taken,  preliminary  to  eventual  operative 
treatment,  to  assist  in  preventing  further  ill  effects.  Thus 
the  patient  should  be  kept  in  bed  with  the  pelvis  raised, 
a  sand  bag  placed  upon  the  abdomen,  and  the  coagulability 
of  the  blood  increased  by  giving  calcium  hypophosphite,  or 
injections  of  -8  or  -9  per  cent,  sodium  chloride  solution,  or 
of  2  per  cent,  gelatine  emulsion. 

If  fever  appears,  pointing  to  sepsis  or  suppuration,  further 
danger  must  be  avoided  by  a  timely  incision  through  the 
vaginal  vault  or  abdominal  wall. 

7.  PREVENTIVE  TREATMENT  IN  PLACENTA  PRAEVIA 
Placenta  praevia,  with  the  serious  consequences  arising 
from  the  low  attachment  of  the  ovum,  may  be  prevented 
by  removing  the  primary  causes  which  produce  it,  and  we 
are  able  to  do  this  in  some  cases,  for  example  in  chronic 
endometritis  and  metritis,  submucous  fibroids,  subinvolution 
of  the  uterus  and  lacerations  of  the  cervix. 

Among  the  consequences  of  placenta  praevia  haemorrhage 
fjom  the  detached  lower  part  of  the  placenta  is  the^mosl^ 

359 


THE   PREVENTION  OF  DISEASE 

serious.  This  may  begin  during  pregnancy  through  the 
stretching  of  the  lower  uterine  segment,  or  may  not  begin 
till  labour  sets  in.  For  these  reasons  preventive  treatment 
consists,  not  only  in  checking  the  haemorrhage,  but  also  in 
raising  the  power  of  resistance  of  the  patient  from  the 
moment  that  a  probable  placenta  praevia  is  diagnosed  by 
the  occurrence  of  frequent  metrorrhagia. 

The  induction  of  premature  labour  is  indicated  when  the 
haemorrhage  is  profuse.  This  is  accomplished  by  dilating 
the  cervix  with  a  hydrostatic  dilator  and  rupturing  the 
membranes  to  prevent  further  detachment  of  the  lower 
part  of  the  placenta,  and  in  cases  where  the  head  does 
not  descend  by  performing  version  and  bringing  down  a 
leg. 

Great  care  should  be  taken  to  ensure  perfect  asepsis  and 
to  prevent  much  air  entering,  which  might  easily  reach  the 
utero-placental  veins  and  cause  air  emboli.  When  ruptur- 
ing the  membranes  we  should  look  out  for  vessels  on  the 
chorion,  as  insertio  velamentosa  is  not  a  rare  occurrence  in 
cases  of  placenta  praevia.  The  third  stage  of  labour  should 
be  closely  watched,  abnormal  separation  of  the  placenta  with 
post  partu.m  haemorrhage  being  almost  the  rule.  . 

11.     Preventive  Treatment  during  Delivery 

1.  GENEEAL  PREVENTIVE  TREATMENT  FOR 
ABNORMALITIES  OF  THE  PELVIS 

To  prevent  abnormal  development  of  the  pelvis  the 
causes  which  produce  it  must  be  treated,  in  most  cases 
during  early  childhood  or  at  puberty.  The  chief  causes  are 
defective  general  development  of  the  body — which  produces 
the  "  generally  contracted  pelvis,"  funnel  shaped  pelvis  and 
dwarf  pelvis — and  rickets.  These  causes  may  in  most  cases 
be  removed  by  suitable  regulation  of  the  conditions  of  life 
and  diet  and  by  the  administration  of  phosphorus.  With  the 
strengthening  and  the  better  development  of  the  bones  of 
the  body,  the  tendency  to  abnormal  development  of  the 
pelvis  disappears.  During  the  period  while  the  bones 
remain  soft   the  patient  should  walk  as  little  as  possible, 

360 


PROPHYLAXIS   IN   MIDWIFERY 

so  that  the  pelvis  may  not  have  any  great  weight  to  bear, 
and  at  puberty  these  patients  should  not  lift  or  carry  heavy 
weights.  The  development  of  the  bony  genital  canal  is 
much  influenced  by  tuberculosis  although  indirectly — 
partly  through  lateral  curvature  of  the  spinal  column 
leading  to  tilting  of  the  pelvis,  and  partly  by  the  formation 
of  oblique  pelvis  through  disease  of  the  hip  and  synostosis. 
Apart  from  these  contractions  and  displacements  of  pelvic 
diameters  which  are  of  importance  in  obstetric  practice, 
exostoses  arising  most  commonly  from  rickets,  less  often 
from  fractures  or  overgrowth,  may  give  rise  to  serious 
conditions  by  the  injury  they  inflict  on  the  soft  parts. 

Even  when  the  unfavourable  conditions  produced  by 
such  abnormalities  are  to  a  considerable  extent  compensated 
for  by  the  yielding  of  joints  and  by  the  compressibility  of 
the  foetal  skull,  yet,  excluding  the  mere  obstruction  to 
delivery  of  the  child,  injuries  may  result  either  to  the  soft 
parts,  such  as  the  uterus  and  vagina,  to  the  joints,  or  to  the 
foetal  skull  bones.  The  more  abnormal  the  position  and 
presentation  of  the  child,  the  earlier  the  membranes  rupture 
before  dilatation  of  the  os,  and  the  more  violent  the  labour 
pains  are,  the  more  readily  will  lacerations  of  the  maternal 
soft  parts  be  produced. 

Preventive  treatment  is  of  great  value  in  these  cases.  The 
results  of  experience  show  that  when  all  complications 
which  add  to  the  difficulty  have  been  removed,  nature  is 
able  to  bring  about  spontaneous  delivery  in  70  per  cent,  of 
the  cases  of  contracted  pelvis.  The  limit  to  the  degree  of 
contraction  in  which  delivery  may  run  a  smooth  course 
is,  according  to  Litzmann,  in  a  true  conjugate  of  3| 
inches ;  and  when  this  limit  is  exceeded  anomalies  in 
position  and  in  presentation  are  found  in  a  markedly  greater 
number  of  cases. 

To  prevent  the  results  which  may  follow  from  a  con- 
tracted pelvis  treatment  should  be  commenced  during 
pregnancy,  as  soon  as  the  diagnosis  of  contracted  pelvis 
has  been  made.  When  the  degree  of  contraction  is  very 
great  the  induction  of  premature  labour  or  even  the 
induction  of  abortion  may  be  indicated,  in  accordance  with 

361 


THE  PREVENTION  OF  DISEASE 

the  rules  laid  down  under  "Artificial  Abortion."  For 
slighter  degrees  of  contraction  it  is  possible  by  frequent 
warm  baths  and  by  work  and  active  exercise  in  the  open 
air  to  prevent  the  regular  duration  of  pregnancy  from 
being  exceeded  ;  indeed  labour  pains  may  thereby  be 
made  to  set  in  a  fortnight  earlier  (Ahlfeld)  and  the  child 
be  full  timed  though  with  very  little  fat  upon  it.  The 
same  principle  may  be  carried  out  by  Prochownik's  dieting 
which  has  been  referred  to  above.  During  the  last  month 
it  is  useful  to  place  the  child  so  that  it  lies  as  in  a  vertex 
presentation  and  to  press  the  skull  into  the  pelvic  brim  ;  it 
should  be  done  for  several  minutes  at  a  time,  several  times 
a  week.  If  labour  has  set  in  the  bag  of  membranes 
should  be  kept  intact  as  long  as  possible,  and  when  they 
have  broken  we  must  prevent  the  further  escape  of  liquor 
amnii.  For  the  latter  purpose  a  hydrostatic  dilator  should 
be  inserted ;  it  is  a  fiddle  shaped  elastic  bag  which  is  then 
filled  with  sterilized  water  or  a  weak  antiseptic  solution 
(Barnes  and  Fehling).  The  pressure  of  the  head  upon  the 
still  undilated  os  uteri  produces  oedema  of  the  lips  and 
leads  to  fissures  and  sepsis ;  it  also  prematurely  excites  very 
strong  and  painful  labour  pains  and  abdominal  efforts, 
which  are  often  rendered  ineffectual  by  partial  tetanic 
spasm.  This  too  is  prevented  by  the  use  of  hydrostatic 
dilators,  which  causes  dilatation  of  the  cervical  canal.  If 
the  external  os  is  still  quite  closed  the  vaginal  dilator  is 
used  only  when  there  is  a  complete  cessation  of  pains. 

This  is  for  vertex  presentations.  But  if  the  vertex  does 
not  enter  the  pelvis  and  the  pains  become  violent  and 
almost  uninterrupted,  and  if  any  contraction  ring  is  plainly 
made  out,  which  is  rising  towards  the  umbilicus  while  the 
region  of  the  bladder  is  flat  and  very  tender,  then  it 
becomes  necessary  to  diminish  the  intensity  of  the  pains 
by  applying  mustard  leaves,  or  very  hot  cloths,  or  employing 
opium  suppositories,  or  the  inhalation  of  ether  or  chloroform 
even  to  the  stage  of  deep  anaesthesia.  An  examination  should 
be  made  to  see  whether  the  position  of  the  head  is  favourable 
or  unfavourable,  and  with  this  we  must  take  into  considera- 
tion--too  the  particular  kind  of  abnormality  of  ;pelvis  which, 

362 


PROPHYLAXIS   IN   MIDWIFERY 

is  present.  Rules  for  these  are  given  in  the  following 
paragraphs. 

The  condition  above  described  readily  leads  on  to  tonic 
spasm  of  the  uterus  and  then  to  rupture  of  the  uterus. 
The  same  result  will  occur  if  a  transverse  presentation  has 
been  assumed  by  the  child  when  the  liquor  amnii  has 
escaped.  While  the  bag  of  membranes  is  intact  a  rupture 
is  improbable.  Preventive  treatment  in  transverse  presen- 
tations consists  in  podalic  version.  Only  very  rarely  is 
cephalic  version  advisable,  and  that  is  when  the  relations 
between  pelvis  and  head  are  very  favourable.  Faulty 
presentations  are  often  produced  by  faulty  postures  in 
pregnancy,  arising  from  lax  abdominal  and  uterine  walls, 
as  with  a  pendulous  abdomen  with  anteflexion  of  the  uterus, 
and  these  can  be  easily  corrected  when  labour  begins. 
Further,  anomalies  in  position  may  be  caused  by  premature 
rupture  of  the  membranes  in  flat  pelves  and  the  carrying 
down  of  limbs  or  of  the  umbilical  cord  by  the  escaping 
liquor  amnii,  when  the  promontory  projects  and  the  head 
cannot  descend  to  fill  the  cervical  canal.  These  anomalies 
must  also  be  speedily  removed  to  prevent  secondary  faulty 
presentations  such  as  brow  or  face  presentations,  and  to 
prevent  direct  danger  to  the  child's  life  when  the  cord  has 
prolapsed. 

Even  when  the  head  has  entered  the  pelvis  it  may 
nevertheless,  especially  in  generally  contracted  pelves, 
become  incarcerated  or  remain  fixed,  and  extraction  by 
forceps  or  perforation  becomes  necessary.  This  must  not 
be  delayed  too  long,  and  the  forceps  should  be  very  carefully 
used  to  avoid  any  risk  of  splitting  open  the  pelvic  joints,  or 
lacerations  and  bruising  of  the  soft  parts,  which  would  lead 
later  to  the  formation  of  fistulae.  In  infundibuliform 
pelves  the  head  sinks  deep  into  the  pelvis  and  rests  upon 
the  ischia.  There  is  no  danger  of  laceration  through 
dilatation,  but  injuries  are  caused  by  the  severe  pressure  or 
by  the  forceps,  and  when  the  labour  pains  are  strong  the 
head  should  not  be  allowed  to  remain  fixed  for  long. 

Preventive  treatment  has  three  objects  in  these  cases : 
(1)    The  removal  of  obstruction  caused  by  faulty  presenta- 

363 


THE  PREVENTION  OP  DISEASE 

tion  aiid  posture  of  the  child,  by  too  early  and  too  copious 
loss  of  liquor  amnii  and  by  abnormalities  in  the  labour 
pains.  (2)  Aseptic  precautions  and  the  avoidance  of  too 
early  interference.  (3)  Timely  interference  to  prevent 
injuries   to  mother  and  child. 

A  careful  consideration  of  the  advance  and  of  the  rota- 
tion of  the  head,  and  of  the  strength  of  the  pains,  gives 
the  conditions  for  the  posture  which  should  be  assumed. 
The  difficulty  caused  by  too  short  a  conjugate  may  be 
lessened  by  putting  the  patient  in  "Walcher's  "  hanging- 
posture,"  because  when  the  legs  are  allowed  to  hang  down 
the  distance  between  the  symphysis  pubis  and  the  pro- 
montory is  increased.  If  we  notice  that  the  advancing 
part  of  the  child  always  tends  to  one  side  the  patient 
should  be  placed  on  that  side.  By  this  lateral  posture  the 
trunk  of  the  child  with  the  fundus  uteri  falls  towards  that 
side  and  the  advancing  part  of  the  child  is  brought  exactly 
over  the  pelvic  inlet.  It  is  useful  too  to  press  the  head 
into  the  inlet  with  every  labour  pain. 

"When  the  head  does  not  enter  the  pelvic  brim  podalic 
version  is  required  in  those  cases  where  the  true  conjugate 
is  not  less  than  2f  inches.  By  ''  version  as  a  preventive 
measure  "  we  understand  those  versions  which  are  under- 
taken when  there  is  only  moderate  contraction  of  the  pelvis, 
either  because  the  advancing  head  tends  again  and  again 
to  pass  to  one  side,  or  because  we  gather  from  the  previous 
history  given  by  the  patient  that  vertex  presentations 
have  previously  always  ended  unfavourably,  whereas  a 
pelvic  presentation  has  ended  favourably. 

In  generally  contracted  pelves  a  true  conjugate  of 
2^  inches  is  the  lowest  limit.  In  the  infundibular  pelvis 
a  distance  of  3  inches  between  the  tuberosities  of  the  ischia, 
the  other  diameters  at  the  outlet  being  normal,  is  the  limit 
for  application  of  forceps. 

But  if  the  distance  between  the  tuberosity  of  the 
ischium  and  the  apex  of  the  sacrum  is  only  2f  inches,  the 
normal  distance  being  3f  inches,  then  the  distance  between 
the  tuberosities  of  the  ischia  must  not  be  less  than  3^  inches ; 
and  this  applies  also  to  cases  where  the  conjugate  at  the 

364 


PROPHYLAXIS   IN  MIDWIFERY 


Flattened  Pelvis. 
True  Conjugate. 

Child. 

Head  movable 

above  the 
Pelvic  Brim. 

Head  tixed 

in  the 
True  Pelvis. 

2|  inches  to  4  inches  .    Living. 
Dead    . 

Version  .     .    . 
Perforation  or 
version. 

Forceps. 

Perforation ;  crani- 
otomy forceps. 

2ii  inches  to  3  inches  . 

Living. 
Dead    . 

Symphysiotonl^ 
Version  .     .    . 

'  in  multiparae. 
Perforation ;  crani- 
otomy forceps. 

2  inches  to  2|  inches  . 

Living. 
Dead    . 

Wait ;  but  if  danger  to  the  mother, 
perforation,  or  possibly  Caesarian 
section. 

Perforation  and  craniotomy  forceps 
or  embryotomy. 

Under  2  inches  .     .     . 

Living  or 
dead. 

Absolute  indication'  for  Caesarian 
section. 

narrowest  part  of  the  pelvic  cavity  is  reduced  to  3|  inches, 
the  normal  being  4|  inches.  Below  these  limits  perforation 
or  symphysiotomy  is  indicated,  unless  the  distance  between 
the  tuberosities  is  less  than  2  inches,  and  then  Caesarian 
section  becomes  necessary. 

2.  SPECIAL  PREVENTIVE  MEASURES  DURING  PREGNANCY 
AND  CHILDBIRTH  FOR  THE  VARIOUS  FORMS  OF  AB- 
NORMAL PELVIS 

In  the  generally-contracted  pelvis  we  must  prevent  the 
presentation  from  becoming  a  fronto-anterior  or  a  brow 
presentation,  and  must  secure  an  occipito-anterior  presenta- 
tion, because  experience  has  shown  that  when  the  occiput 
sinks  very  low  it  is  possible  for  the  head  to  pass.  It  may 
be  aided  by  putting  the  patient  in  the  lateral  posture,  on 
the  side  on  which  the  occiput  lies,  and  by  manually  assisting 
the  rotation  of  the  head.  The  same  holds  good  for  the 
after-coming  head  in  pelvic  presentations :  it  should  be 
pressed  into  the  pelvic  brim  and  the  chin  be  kept  in  close 

365 


THE  PEEVENTION  OF  DISEASE 

contact  with  the  breast.  Eclampsia  occurs  frequently  with 
this  kind  of  pelvis,  and  we  should  be  on  the  lookout  for  its 
premonitory  signs. 

With  regard  to  all  preventive  treatment,  including  the 
induction  of  premature  labour,  we  must  bear  in  mind  that 
we  have  to  consider  not  only  the  degree  of  contraction  of 
the  true  conjugate,  but  also  the  fact  that  this  is  complicated 
by  contraction  of  all  the  other  diameters. 

When  the  head  is  fixed  and  the  pains  are  strong  but 
no  progress  is  made,  it  is  best  not  to  wait  too  long, 
especially  when  the  child  is  dead  or  its  life  endangered. 
There  is  great  danger  of  injury  to  the  tissues  by  pressure, 
and  forceps  should  not  be  used  at  all,  or  only  with  great 
caution,  if  the  child  is  still  alive. 

The  best  preventive  treatment,  when  the  diagnosis  is 
made  sufficiently  early,  is  the  induction  of  premature  labour. 

In  the  simple  flattened  pelvis  the  preventive  treatment 
is  that  of  rickets  and  the  induction  of  premature  labour 
given  above. 

The  pregnant  and  retroflexed  uterus  which  has  become 
incarcerated  should  be  replaced  in  its  normal  position  during 
the  second  month.  For  a  pendulous  abdomen  an  abdominal 
belt  should  be  worn ;  it  should  also  be  worn  during  parturi- 
tion when  the  uterus  falls  too  much  forwards  or  too  much 
to  one  side,  as  this  tends  to  produce  lateral  flexion  of  the 
child's  cervical  spine  and  extreme  obliquities  of  the  head  ; 
the  uterus  may  also  be  supported  by  cushions.  It  should 
be  remembered  that  moderate  obliquity  with  descent  of  the 
narrower  frontal  region  into  the  pelvic  brim  is  favourable 
and  should  be  encouraged. 

In  a  flattened  pelvis  which  will  not  allow  the  head  to 
pass  through,  the  imminent  danger  of  rupture  of  the  uterus 
must  be  prevented  by  the  methods  already  described.  The 
premature  rupture  of  the  membranes  must  also  be  pre- 
vented, for  it  predisposes  to  rupture  of  the  uterus  and 
favours  prolapse  of  the  umbilical  cord  or  of  a  hand  or  foot. 
The  strength  of  the  labour  pains  must  be  restrained  if 
necessary. 

In  the  generally-contracted  and  flattened  pelvis  all  these 

366 


PROPHYLAXIS  IN  MIDWIFERY 

difficulties  during  pregnancy  and  at  cbildbirtli  are  increased. 
This  pelvis,  so  far  as  the  pelvic  cavity  is  concerned,  has  all 
the  peculiarities  of  a  simple  generally-contracted  pelvis, 
and  descent  of  the  forehead  must  be  prevented  and  an 
occipital  presentation  be  brought  about.  Presentation  of 
the  forehead  may,  in  this  form  of  pelvis,  much  more  readily 
necessitate  perforation  and  destruction  of  the  child.  A 
combination  of  posterior  parietal  and  occipital  presentation 
is  very  favourable. 

In  osteomalachic  and  similar  pelves  the  prognosis  of 
childbirth  depends  less  upon  the  degree  of  deformity  than 
upon  the  question  whether  the  pelvis  is  soft  or  has  become 
ossified  and  rigid.  Phosphorus  should  be  given  at  the  very 
first  appearance  of  well  marked  symptoms  :  these  are  pains 
in  the  bones,  first  in  the  horizontal  pubic  rami ;  cramps  in 
the  muscles ;  softening  of  the  bones,  occurring  first  at  the 
pelvic  outlet ;  and  a  waddling  gait. 

In  malacosteon  pelves  spontaneous  delivery  or  delivery 
by  forceps  is  possible.  One  need  therefore  only  try  to  obtain 
a  favourable  position  and  presentation  of  the  child. 

"With  a  rigid  rostrated  pelvis  the  danger  of  laceration 
must  be  prevented ;  it  varies  with  the  degree  of  contraction, 
and  Caesarian  section  may  possibly  be  required. 

In  funnel  shaped  pelves  the  rotation  forwards  of  the 
occiput  must  be  assisted.  Timely  and  cautious  interference 
is  required.  Possibly  symphysiotomy  may  be  advisable  to 
prevent  injurious  pressure  and  straining  of  the  sacro-iliac 
articulations. 

In  oblique  pelves  with  a  considerable  degree  of  con- 
traction of  one  half,  there  remains  only  the  other  half 
of  the  pelvic  inlet,  and  the  conditions  are  similar  to  those 
of  the  generally  contracted  pelvis,  and  an  occipital  presenta- 
tion is  the  most  favourable.  An  endeavour  must  be  made 
to  bring  the  sagittal  suture  into  the  shorter  oblique 
diameter,  so  that  the  descending  occiput  may  be  turned 
towards  the  flattened  or  narrowed  half  of  the  pelvis. 
Naegele's  oblique  pelvis,  produced  by  an  asymmetry  of  the 
alae  of  the  sacrum  and  synostosis,  is  of  worse  prognosis  than 
the  oblique  pelvis  produced  by  scoliosis  or  anchylosis  ;  for  in 

367 


THE  PREVENTION  OF  DISEASE 

the  Naegele  pelvis  forceps  and  version  are  almost  invariably 
harmful. 

3.  PEEVENTIVE  TREATMENT  OF  LACERATIONS  OF  THE 

UTERUS 

Among  the  rare  lacerations  of  the  uterus  during  preg- 
nancy very  few  afford  an  opportunity  for  preventive 
treatment,  since  most  of  them  are  the  result  of  criminal 
attempts  to  procure  abortion  or  are  ruptures  of  rudimentary 
uterine  cornua.  Old  scars,  after  Caesarian  section,  which 
have  given  way  form  the  remainder.  The  suturing  should 
therefore  be  very  carefully  done  in  this  operation.  The  use 
of  catgut  and  inclusion  of  the  endometrium  in  the  stitches 
are  now  condemned.  Various  operators  have  however  had 
very  good  results  with  both.  Miiller  always  sutures  the 
endometrium  independently  by  itself. 

The  chief  point  of  importance  seems  to  be  an  exact 
adjustment  of  the  edges  of  the  wound  in  the  uterus  and 
the  avoidance  of  sutures  which  are  too  tense.  If  the 
condition  of  the  patient  admits  of  it,  the  serous  coat  should 
also  in  addition  be  separately  sutured.  The  preventive 
treatment  of  ruptures  of  the  uterus  which  occur  during 
parturition  has  already  been  described  under  "  General 
Remarks  in  Anomalies  of  the  Pelvis."  All  that  applies  to 
obstruction  in  delivery  there  is  applicable  also  here. 
When  the  obstruction  which  blocks  the  pelvic  entry  cannot 
be  removed,  as  in  contracted  pelvis,  tumours,  stenoses, 
hydrocephalus,  and  oblique  positions  of  the  child,  and  the 
pains  are  strong  and  increasing  and  the  liquor  amnii  has 
escaped  prematurely,  there  is  always  the  danger  of  lacera- 
tion of  the  lower  uterine  segment.    The  treatment  embraces : 

1.  The  removal  of  the  obstruction.  This  may  be  effected 
by  Walcher's  "  hanging  posture,"  or  by  symphysiotomy ; 
or  if  an  ovarian  cyst  is  the  cause  of  the  obstruction  it  may 
be  punctured  ;  a  fibroid  may  be  pushed  upwards  into  the 
abdomen  or  removed.  The  presentation  of  the  foetus  may 
be  improved,  version  may  be  performed,  a  hydrocephalic 
head  may  be  punctured,  or  the  cervix  may  be  dilated  by 
a  hydrostatic  dilator. 

368 


PEOPHYLAXIS  IN  MIDWIFERY 

2.  Prevention  of  laceration  by  recognizing  the  approach.- 
ing  danger  by  the  appearance  of  Bancll's  contraction  ring. 
Whein  this  appears  version  must  on  no  account  be 
attempted,  and  the  patient  must  be  cautioned  against 
straining.  She  should  be  anaesthetised  and  labour  should 
then  be  terminated  at  once  by  perforation,  decapitation, 
or  Caesarian  section. 

3.  Prevention  of  the  serious  consequences  of  laceration. 
Most  dangerous  of  all  are  the  complete  ruptures  which  at 
the  same  time  open  into  the  vaginal  vault  and  the  trans- 
verse ruptures  of  the  body  of  the  uterus,  because  in  both 
these  cases  germs  which  have  got  into  the  vagina  by 
explorations  and  by  operations  may  pass  direct  into  the 
abdominal  cavity.  If  far  from  a  hospital  it  is  best  even 
today  in  complete  rupture  of  the  uterus  to  deliver  the 
child  through  the  natural  passages,  even  when  it  has 
passed  through  into  the  -abdominal  cavity,  and  afterwards 
to  plug  with  iodoform  gauze.  Lacerations  which  bleed 
much  should  be  stitched  up.  When  there  is  extensive 
laceration  and  undermining  of  the  broad  ligaments  the 
uterus  must  be  removed  to  prevent  infection,  for  which  the 
necrosed  tissues  and  the  blood  clots  afford  a  favourable 
soil  in  cavities  of  the  connective  tissue. 

In  these  cases,  as  indeed  in  obstetric  practice  generally, 
frequent  examinations  and  futile  operative  procedures 
should  be  avoided :  if  a  laceration  occurs  after  such  inter- 
ference the  prognosis  is  certainly  very  much  worse. 

The  prognosis  is  much  better  when  the  laceration,  even 
if  complete,  is  caused  by  abrasion  of  the  tissues,  because 
a  circumscribed  adhesive  peritonitis  will  at  once  close  it. 
Genito-urinary  fistulae  are  very  fatal.  Those  occurrences 
may  be  prevented  in  generally  contracted  pelves  and  in 
the  so-called  "  spinous  pelvis,"  if  the  head  is  not  permitted 
to  remain  fixed  and  stationary  for  too  long  a  time  when 
the  pains  are  strong  :  the  head  should  be  carefully  levered 
with  the  forceps,  which  should  not  be  put  on  while  the 
OS  uteri  is  insufficiently  dilated. 


369  BB 


THE  PEE\^NTION   OF  DISEASE 


4.  PEEVENTIVE   TEEATMENT  FOE  LACEEATIONS  OF  THE 

GENITAL  CANAL— CEEVIX,  VAGINA,  PEEINEUM 

The  usual  laceration  of  the  os  uteri  heljDS  delivery  and 
may  almost  be  regarded  as  a  physiological  event,  and 
may  even  be  imitated  with  advantage  by  making  small 
incisions.  Deep  lacerations  of  the  cervix  are  mechanically 
produced  in  most  cases  by  the  too  early  use  of  forceps.  If 
it  is  necessary  to  apply  forceps  early,  the  necessary  space 
should  first  be  made  by  crucial  incisions  through  the  lips  of 
the  OS  uteri,  avoiding  the  commissures  of  the  lips.  In  this 
way  laceration  is  prevented,  or  if  laceration  should  take 
place  its  direction  has  been  determined  by  the  incision 
and  the  uterine  vessels  wbich  lie  laterally  will  be  avoided. 
The  lacerations  must  be  carefully  stitched  up  to  prevent 
loss  of  blood  and  infection.  For  stenosis,  atresia  and 
cancer  as  causes  of  lacerations  of  the  cervix,  reference  should 
be  made  to  those  sections. 

Lacerations  of  the  vaginal  vault  are  extremely  serious, 
because  the  connective  tissue  of  the  broad  ligaments  may 
be  extensively  undermined  even  as  far  as  the  peritoneum 
which  may  be  torn.  Some  of  these  lacerations  are  the 
result  of  mechanical  violence ;  others  are  caused,  like  the 
ruptures  of  the  lower  uterine  segment,  by  too  great  a 
tension  of  the  vaginal  vault  when  the  uterine  contractions 
are  tonic  in  character  or  expend  their  force  in  an  unfavour- 
able direction,  for  example  when  the  abdomen  is  pendulous  or 
when  the  patient  is  standing  up  and  bending  too  far  forward. 
Others  again  are  caused  by  primary  rigidity  and  inelasticity 
of  the  tissues.  By  careful  watching  uiany  of  the  lacera- 
tions may  be  prevented ;  in  some  it  is  however  impossible 
to  foresee  and  to  prevent  the  laceration,  and  this  applies 
especially  to  exhausted  women  who  have  borne  many 
children.  The  symptoms  of  the  laceration  may  not  be  at 
all  conspicuous  at  first,  but  when  the  laceration  has 
occurred  delivery  should  be  completed  as  soon  as  possible, 
otherwise  internal  haemorrhage  may  follow.  If  the  injury 
is  not  very  extensive    the   laceration  should  be  stitched, 

370 


PROPHYLAXIS   IN  MIDWIFERY 

but  if  very  severe  the  uterus  will  have  to  be  removed,  or 
at  least  plugged  with  iodoform  gauze. 

Lacerations  in  the  middle  of  the  vagina  are  longitudinal, 
generally  the  result  of  violence  and  brought  about  by  the 
too  hasty  introduction  of  forceps  or  too  early  raising  of 
the  handles  of  the  forceps.  They  should  be  at  once  sutured : 
they  often  cause  vesico-vaginal  fistulae,  but  rarely  recto- 
vaginal fistulae. 

Lacerations  at  the  vulval  orifice  and  of  the  perineum 
may  be  produced  by  very  rapid  passage  of  the  head,  by 
a  large  and  hard  head  when  the  perineum  is  rigid  and 
inelastic,  by  passage  of  the  occiput  over  the  perineum  in 
brow  and  in  face  presentations,  by  wrong  posture  of  the 
patient  at  the  moment  of  birth,  such  as  sitting  up.  When 
the  child's  shoulders  are  very  broad  laceration  may  be 
caused  by  the  passage  of  the  posterior  shoulder  if  the  child's 
head  is  allowed  to  fall  backwards,  or  if  traction  ir.  made. 
It  is  also  produced  by  raising  the  handles  of  the  forceps 
too  quickly.  Many  lacerations  are  therefore  avoidable. 
Appropriate  preventive  treatment  consists  in  protection 
of  the  perineum,  and  occasionally  lateral  incisions  in  the 
perineum  may  be  required.  The  latter  are  only  needed 
when  there  is  danger  of  laceration  of  the  whole  perineum 
(complete  laceration  of  the  third  degree),  or  when  it  is 
desirable  to  hasten  the  birth  of  the  child  ;  such  incisions 
heal  less  well  than  lacerations  of  moderate  severity.  In 
suturing  these  deep  incisions  which  are  midway  between 
the  anus  and  tuber  ischii,  it  is  very  important  to  fit 
accurately  together  the  surfaces  of  the  divided  levator 
ani  muscles. 

Protection  of  the  perineum  consists  in  relieving  the 
perineum  from  excessive  tension  ;  the  right  thumb  and 
index  finger  placed  outside  the  labia  draw  together  the 
tense  skin,  while  the  thenar  eminence  lies  against  the 
perineum  and  presses  the  head  forward  towards  the 
symphysis  and  keeps  it  fixed  there.  During  a  pain 
the  head  is  held  back  by  the  left  hand  till  the  anterior 
fontanelle  is  born.  After  this  straining  efforts  should  be 
forbidden  during  a  pain ;  the  patient  should  be  urged  to 

371 


THE  PREVENTION   OE  DISEASE 

strain  in  the  intervals  between  the  pains,  and  the  perineum 
should  be  turned  back  at  the  same  time  so  that  the  face 
may  be  born.  In  delayed  birth  of  the  head  it  is  useful  to 
express  the  head  and  protect  the  perineum  by  the  Ritgen- 
Pehling  method,  that  is  by  manipulation  from  the  sacrum 
and  perineum  (posterior  perineal  method),  or  by  the  Smellie- 
Ritgen  method,  that  is  by  manipulation  from  the  rectum. 
The  best  posture  for  the  patient  at  this  moment  is  the 
dorsal  with  the  knees  raised  or  the  lateral  position  with  the 
knees  drawn  up. 

The  birth  of  the  shoulders  also  requires  care.  The  head 
should  first  be  lowered  to  allow  the  anterior  shoulder  to 
appear,  and  be  fixed  behind  the  symphysis.  Then,  while 
the  perineum  is  protected,  the  posterior  shoulder  should  be 
guided  over  the  perineum  and  pressed  towards  the  sym- 
physis, the  head  at  the  same  time  being  raised.  This  pro- 
cedure may  be  aided  by  grasping  the  axilla.  "When  the 
shoulders  are  too  large  absolutely,  division  of  a  clavicle  is 
indicated  to  make  it  possible  for  the  shoulders  to  fall  to- 
gether. 

"When  the  head  has  been  born  by  forceps  as  far  as  the  large 
fontanelle,  it  is  best,  especially  in  primiparae  or  when  the 
perineum  is  rigid,  to  remove  the  blades  of  the  forceps  while 
the  four  fingers  support  the  perineum  and  the  thumb  holds 
back  the  head.     Afterwards  the  head  should  be  expressed. 

When  laceration  of  the  perineum  has  occurred  it  should 
at  once  be  sutured  to  prevent  both  immediate  and  remote 
sequelae.  The  latter  have  been  described  in  the  section  on 
Gynaecology ,  under  "  Prolapse "  and  "  Plastic  Perineal 
Operations."  The  patient  should  be  kept  in  bed  rather 
longer,  because  of  the  granulating  tissues  and  the  ease 
with  which  the  wound  is  apt  to  ulcerate  and  thus  extend 
further.  The  most  dangerous  lacerations  are  the  complete 
lacerations,  because  faeces  may  reach  the  vagina.  The 
parts  should  be  sutured  after  the  expulsion  of  the  placenta, 
otherwise  primary  union  may  fail,  but  not  later  than  six 
hours  after  delivery  ;  secondary  suturing  generally  fails. 

To  suture  a  complete  laceration  the  following  method  is 
adopted.     The  entire  surface  of  the  wound  up  to  the  re- 

372 


PROPHYLAXIS  IN  MIDWIFERY 

motest  angle  in  the  vagina  should  be  exposed.  The  wound 
has  the  shape  of  a  butterfly,  the  thinner  middle  part  corre- 
sponds to  the  deepest  part  of  the  laceration  in  the  vagina,  and 
the  two  wings  correspond  with  the  lateral  walls  formed  by  the 
rent  in  the  larger  mass  of  the  perineal  body.  Commencing 
at  the  deep  angle  of  the  rent  in  the  vagina,  catgut  sutures 
should  be  inserted  to  unite  the  rectal  mucous  membrane,  in 
such  a  way  that  the  sutures  may  include  sufficient  connec- 
tive tissue  and  the  ends  of  the  sutures  come  to  lie  in  the 
lumen  of  the  rectum.  The  bowel  should  previously  have  been 
thoroughly  emptied  by  an  enema  and  the  rectum  should 
have  been  washed  out.  Then  similarly  the  vaginal  rent 
should  be  sutured,  the  sutures  passing  deeply  into  the  recto- 
vaginal septum  and  being  tied  inside  the  vagina ;  catgut 
or  silk  or  celluloid  thread  may  be  used.  These  sutures 
should  only  reach  to  the  place  occupied  by  the  former 
frenulum  perinaei,  because  the  sutures  of  the  perineum 
itself  must  be  entered  in  another  direction,  commencing 
from  the  anus,  in  order  that  the  correct  form  of  the  peri- 
neum may  be  restored.  These  sutures  may  be  of  silver 
wire,  silkworm,  or  celluloid  thread.  The  ligatures  must  lie 
at  right  angles  to  the  perineum  and  be  entered  therefore 
perpendicularly  to  the  surface  of  the  perineum.  Fine 
superficial  sutures  may  be  added  to  remove  any  irregularity 
or  gaping  of  the  edges  of  the  wound  and  at  the  sphincter 
ani  and  frenulum  perinei.  The  weakest  spot  is  at  the  deep 
angle  in  the  vagina  where  the  recto-vaginal  septum  is 
very  thin.  Here  the  sutures  must  be  so  placed  that  the 
vaginal  sutures  do  not  touch  the  rectal  sutures ;  and  they 
must  not  be  too  tight,  so  as  to  avoid  injury  to  and  death  of 
the  tissues. 

The  after  treatment  is  most  important,  because  the 
chances  of  perfect  union  are  reduced  by  the  fact  that  the 
patients  in  whom  lacerations  occur  are  generally  those 
who  have  little  power  of  resistance.  The  strictest  cleanli- 
ness, a  trustworthy  trained  nurse  and  obedience  on  the 
part  of  the  patient  are  further  conditions  required.  As  to 
the  nurse  I  would  particularly  emphasize  this  point,  be- 
cause it  happened  to  me  once,  when  the  relatives  preferred 

373 


THE  PREVENTION  OF  DISEASE 

to  choose  their  own  nurse,  that  instead  of  giving  the  castor 
oil  prescribed,  the  nurse  gave  an  oil  enema  either  from 
misunderstanding  or  because  she  thought  it  was  better, 
and  in  a  few  hours  the  patient,  who  before  was  doing  very 
well,  suffered  from  endometritis  which,  in  spite  of  all  that 
could  be  done,  led  to  parametritis  on  both  sides  which 
lasted  for  months :  the  nozzle  of  the  sj^ringe  had  perforated 
the  sutured  recto- vaginal  septum. 

It  is  best  for  this  reason  to  make  an  easy  passage  for 
flatus  by  inserting  a  drainage  tube  covered  with  iodoform 
gauze  or  a  Simon's  urethral  speculum.  Evacuation  of  the 
bowels  should  be  prevented  for  five  days  by  tincture  of 
opium ;  and  liquid  diet  should  be  given  for  a  week.  The 
line  of  suture  itself  should  not  be  touched,  but  lotion  may 
be  frequently  run  over  the  surface,  and  it  may  be  dusted 
with  airol  or  dermatol,  or  smeared  with  airol  paste,  which 
melts  at  the  temperature  of  the  body.  The  vaginal  sutures 
should  not  be  touched. 

All  this  holds  good,  mutatis  mutandis,  for  lacerations  of 
the  perineum  of  the  first  and  second  degrees,  which  extend 
at  furthest  only  to  the  sphincter  ani.  It  must  be  empha- 
sized that  often  when  the  perineum  seems  intact  externally 
there  may  yet  be  a  deep  perineal  laceration  when  a  vaginal 
laceration  in  the  fossa  navicularis  has  extended  into  the 
perineal  body.  The  results  of  these  are  similar  to  those 
of  laceration  of  the  first  and  second  degree,  and  the  lacera- 
tions should  therefore  be  carefully  sutured. 


5.  PEEYENTIVE  TEEATMENT  FOR  DIFFICULTIES  ARISING 
FROM  ANOMALIES  OF  POSITION  AND  OF  FORM  OF 
THE   GENITAL  ORGANS 

Difficulties  arising  from  faulty  development  of  the  genital 
organs  may  be  the  result  of  weakness  of  the  muscular  tissue, 
such  as  lacerations,  protracted  labour,  and  post  partum 
haemorrhages,  or  they  may  be  the  result  of  the  expulsive 
contractions  of  the  uterus  acting  in  a  wrong  direction, 
obliquely  to  the  pelvic  brim  as  in  face  presentations,  obliquity 

374 


PROPHYLAXIS  IN  MIDWIFERY 

of  the  uterus,  pelvic  presentations  and  transverse  pre- 
sentations. Sometimes  in  uterus  bicornis  the  second 
and  empty  uterine  cornu  becomes  incarcerated  like  a 
tumour  under  the  promontory :  it  should  be  early  pushed 
away  from  under  the  promontory  or  possibly  be  removed. 
These  difficulties  may  when  they  first  appear  be  removed 
by  correct  postural  treatment  or  by  some  obstetric  proce- 
dure, after  dilating  with  a  hydrostatic  dilator,  and  the 
threatened  dangers  may  thus  be  prevented. 

The  troubles  arising  from  anteflexion  and  lateral  flexion 
of  the  uterus  are  generally  those  of  laxity  of  the  abdom- 
inal walls  and  lead  to  faulty  presentation  when  the  advan- 
cing part  enters  the  pelvic  brim,  as  in  obliquity  of  the 
head,  face  and  brow  presentations  and  transverse  pre- 
sentations. They  produce  also  lateral  flexion  of  the  trunk 
of  the  child. 

Preventive  treatment  consists  in  keeping  the  uterus  in 
position  by  a  binder,  in  placing  the  patient  on  the  corres- 
ponding side  so  that  the  presenting  part  may  be  brought  over 
the  inlet  of  the  pelvis,  in  supporting  the  uterus  by  cushions, 
in  pressing  the  occiput  into  the  pelvic  brim,  in  internal 
manual  correction  of  an  unfavourable  presentation  and 
version.  By  these  measures  the  head  may  be  made  to 
enter  the  brim  and  become  fixed  or  a  foot  presentation 
may  be  obtained. 

With  retroflexion  when  birth  is  at  term  we  need  to 
consider  only  the  partial  bulging  or  pouches  produced,  the 
remainder  of  the  body  of  the  uterus  is  generally  anteflexed. 
Many  causes  may  lead  to  this  :  for  example  adhesions  after 
parametritis,  adhesions  after  hysteropexies  making  it  im- 
possible for  the  anterior  uterine  wall  to  expand  in  preg- 
nancy. Other  causes  are  subserous  fibroids  and  ovarian 
cysts,  or  the  foetal  head  may  remain  below  the  promontory 
in  incarceration  of  the  gravid  retroflexed  uterus  after  the 
trunk  of  the  child  has  risen  out  of  the  pelvis,  and  lastly 
with  pendulous  abdomen  it  may  be  caused  by  the  faulty 
direction  in  which  the  uterine  forces  act. 

The  head  is  thereby  pushed  aside  from  its  normal  median 
position  over  the  pelvic  brim,  and  is  pressed  into  the  dis- 

376 


THE   PEEVENTION  OF  DISEASE 

tended  lower  uterine  segment.  Laceration  may  occur  or 
delivery  may  become  impossible. 

The  object  of  preventive  treatment  first  of  all  should  be 
to  remove  the  primary  cause,  and  when  this  is  impossible 
we  must  endeavour  to  correct  the  abnormal  position  of  the 
head.  For  the  latter  it  generally  becomes  necessary  to 
bring  the  whole  cervical  canal  into  the  axis  of  the  pelvis  : 
this  can  be  accomplished  by  a  hydrostatic  dilator,  which  at 
the  same  time  serves  to  dilate  the  cervix.  If  this  fails  an 
incision  must  be  made  through  the  anterior  wall  of  the 
cervix.  The  same  treatment  must  be  followed  if  rupture 
of  the  uterus  threatens.  If  a  tumour  is  present  and  at- 
tempts to  push  it  out  of  the  pelvis  have  failed,  we  should 
wait  to  see  what  effect  the  labour  pains  will  have.  A  cyst 
should  be  punctured  or  incised  from  the  vagina. 

Many  obstructions  situated  in  the  genital  canal  may  be 
removed  during  pregnancy  or  shortly  before  delivery  or 
during  labour  itself.  Among  these  are  stenoses  and  septa 
of  the  vagina  which  may  be  congenital  or  acquired. 
Cicatrices  of  the  cervix  occurring  after  extensive  opera- 
tions and  obliteration  of  the  external  os  in  primiparae  may 
also  be  dealt  with.  Cystocele  due  to  prolapse  of  the  vagina, 
perhaps  complicated  by  the  j)resence  of  a  vesical  calculus 
in  the  cystocele,  and  lastly  subcutaneous  haomatomata  and 
other  vaginal  tumours  may  also  need  treatment. 

Simple  septa  and  stenoses  of  the  vagina  should  be  divided 
and  bleeding  points  ligatured,  or  they  may  be  forcibly 
stretched  or  incised.  If  a  considerable  degree  of  atresia 
exists  a  new  vaginal  passage  may  be  made,  by  several 
operations,  but  it  will  later  again  become  constricted.  It 
would  however  be  difficult  to  deliver  a  living  child  through 
the  passage,  and  in  some  cases  Caesarian  section  is  unavoid- 
able. To  prevent  haemorrhage  when  there  is  a  haematoma, 
especially  in  twin  pregnancies,  the  child  must  be  quickly 
extracted,  the  haematoma  incised,  the  bleeding  points 
ligatured  and  the  cavity  plugged. 


376 


PROPHYLAXIS   IN  MIDWIFERY 

6.  PREVENTIVE  TREATMENT  FOR  DIFFICULTIES  ARISING 
FROM   TUMOURS  OF  THE   GENITAL   ORGANS 

The  measures  to  be  taken  against  complications  during 
pregnancy  and  at  the  onset  of  premature  labour  have 
already  been  described  above  ;  there  are  other  measures 
which  have  reference  to  delivery  at  term. 

The  consequences  resulting  from  large  intramural  and 
from  cervical  myomata  are  similar  to  those  which  follow 
contracted  pelves.  The  j^reventive  treatment  at  the  onset 
of  labour  at  term  is  the  same  as  that  for  contracted 
pelvis,  the  various  degrees  of  contraction  have  the  same 
relative  effect,  and  prolapse  of  the  umbilical  cord  or  of  the 
extremities  is  apt  to  occur. 

Submucous  myomata  of  the  cervix  often  become  enucle- 
ated and  expelled.  Preventive  treatment  should  aim  at 
assisting  this  natural  process,  and  at  preventing  infection 
of  the  site  of  the  tumour. 

Subserous  fibroids  situated  higher  up  are  often  raised  out 
of  the  pelvis  by  the  labour  pains,  though  all  attempts  to 
push  them  up  had  failed.  But  if  this  does  not  occur  and 
the  tumour  cannot  be  removed  then  Caesarian  section  be- 
comes necessary  and  should  be  followed  by  removal  or  total 
extirpation  to  prevent  the  sepsis  which  is  so  apt  to  occur. 

Even  after  spontaneous  delivery  it  is  often  advisable  to 
carry  out  this  radical  operative  procedure,  because  the 
bruised  tumour  so  readily  leads  to  severe  post  partum 
haemorrhage,  to  retention  of  the  placenta,  or  to  suppura- 
tion. 

Through  the  lack  of  room  in  the  pelvis  faulty  attach- 
ment of  the  ovum  often  exists  as  a  complication,  producing 
placenta  praevia  or  extra-uterine  gestation,  and  these  must 
also  be  considered  in  treating  the  case. 

Among  ovarian  tumours  the  most  dangerous  are  the 
fibrous  tumours  when  they  become  wedged  in  under  the 
promontory ;  but  in  all  ovarian  tumours  there  are  the 
dangers  of  septic  infection  after  bruising  of  the  tumour,  or 
avulsion  of  the  tumour,  or  twisting  of  the  pedicle  when 
the  tumour  is  pulled  up  into  the  abdominal  cavity.    Accord- 

377 


THE  PREVENTION  OF  DISEASE 

ing  to  the  degree  of  narrowing  of  the  pelvis  lacerations  of 
tlie  uterus  or  vagina  may  also  occur. 

These  dangers  can  be  prevented  either  by  pushing  the 
tumour  out  of  the  pelvis,  or  by  reducing  it  in  size,  or  by 
removing  it,  or  finally  by  Caesarian  section  and  subsequent 
removal  of  the  tumour. 

When  the  cervix  is  infiltrated  by  carcinomatous  growth 
laceration  is  apt  to  occur,  because  the  vaginal  part  cannot 
be  dilated.  If  it  is  impossible  to  make  a  passage  by 
deep  incisions  or  by  an  incision  through  the  anterior  wall 
of  the  cervix,  the  only  alternative  which  remains  is 
Caesarian  section  and  subsequent  removal  of  the  body  of 
the  uterus  from  above  and  of  the  cervix  from  the  vagina  in 
order  to  avoid  peritonitis, 

7.  PREVENTIVE  TREATMENT  FOR  DIFFICULTIES  IN 
LABOUR  CAUSED  BY  ABNORMAL  PRESENTATIONS 
AND  POSTURES  OF  THE  CHILD. 

In  each  case  we  must  determine  exactly  whether  the 
faulty  position  of  the  child  is  a  primary  condition  or,  as  is 
more  common,  a  secondary  condition.  "We  shall  then  be 
able  to  select  the  method  to  remove  the  obstruction,  and 
the  method  for  secondary  forms  is  often  very  di£ferent  from 
that  required  to  remove  the  primary  anomalies  of  position. 

(a)  Preventive  treatment  of  complications  in  normal  pre- 
sentations. 

In  occipito-anterior  presentations  there  will,  under 
favourable  circumstances,  be  only  two  conditions  which 
may  arise  and  require  treatment.  The  head  may  be  low 
and  yet  advance  slowly  :  the  cause  of  this  may  be  that  the 
cord  is  twisted  several  times  round  the  neck  and  thus  may 
endanger  the  child's  life.  This  condition  would  be  probably 
present  if  the  heart  sounds  are  persistently  below  100  or  over 
160,  if  there  is  umbilical  souffle,  the  uterus  painful,  and  the 
head  does  not  press  upon  the  examining  finger  or  upon  the 
perineum  though  the  labour  j)ains  are  strong;  the  head 
is  also  prevented  from  rotating  forwards,  and  sometimes 
the  cord  may  be  felt  round  the  neck  by  a  finger  in  the 
rectum  covered  with  an  indiarubber  finger  stall.  For  such 
a  case  immediate  extraction  by  forceps  is  indicated. 

378 


PROPHYLAXIS   IN  MIDWIFERY 

Further,  the  perineum  may  require  to  be  protected  during 
the  passage  through  the  vulval  orifice.  It  should  be  borne 
in  mind  too  that  in  the  second  vertex  presentation  the  head 
may  very  readily  become  transverse,  or  may  become  an 
occipito-posterior  presentation  by  rotation  of  the  occiput 
backwards.  This  backward  rotation  may  be  prevented  by 
placing  the  patient  on  her  right  side  or  by  bringing  the  occi- 
put to  the  front  by  means  of  the  right  blade  of  the  forceps. 

Occipito-posterior  presentations  are  favourable  when  the 
chin  is  close  to  the  chest,  but  the  perineum  is  endangered 
by  the  passage  over  it  of  the  occiput. 

This  is  the  case  also,  and  even  to  a  greater  degree,  in 
face  presentations  with  the  chin  to  the  front.  If  there  is 
great  pelvic  contraction,  or  the  child  is  very  large  and  the 
skull  hard,  the  risk  of  bruising  of  the  maternal  soft  parts 
and  the  formation  of  urogenital  fistulae  is  great.  There 
is  danger  too  for  the  child  through  the  excessive  stretching 
of  the  cervical  spinal  column  and  spinal  cord,  and  also  from 
cerebral  apoplexy  as  the  result  of  pressure  on  the  jugular 
veins. 

The  best  treatment  is  to  convert  it  into  an  occipito- 
anterior presentation  while  the  head  is  still  movable,  or 
later  by  timely  extraction  with  forceps  when,  in  spite  of 
strong  labour  pains,  no  progress  is  noted.  When  examining 
care  must  be  taken  not  to  injure  an  eye. 

Among  the  causes  which  lead  to  face  presentations  are 
pendulous  abdomen  and  contracted  pelvis,  and  to  prevent  a 
presentation  from  becoming  a  face  presentation  the  uterus 
should  be  held  back  by  a  binder,  the  patient  should  be 
placed  on  her  side  (the  side  corresponding  with  the  child's 
occiput),  and  the  uterus  should  be  supported  and  the  occiput 
pressed  into  the  pelvic  brim.  If  the  tendency  of  the  head 
to  take  up  an  abnormal  position  persists  version  should  be 
performed  as  a  preventive  measure. 

Pelvic  presentations  are  often  dangerous  for  the  child, 
because  after  the  birth  of  the  breech  attempts  at  respiration 
are  made  by  the  unborn  head  directly  the  cord  becomes 
pressed  upon,  and  prolapse  of  the  cord  is  apt  to  occur.  This 
sign  and  enfeeblement  of  the  heart  sounds  after  a  pain  are 

379 


THE  PREVElvTION   OF  DISEASE 

indications  for  extraction  of  the  child,  and  the  further  pre- 
cautionary measures  already  described  under  "  Extraction  " 
must  be  adopted. 

"When  we  remember  the  causes  which  produce  pelvic 
presentations  it  becomes  evident  that  interference  to  alter 
the  presentation  is  not  required.  "When  the  child  is  small 
and  premature  a  pelvic  presentation  adds  no  danger  to 
delivery ;  so  too  when  the  foetus  is  malformed  or  macerated. 
In  twin  pregnancies  one  child  has  very  often  a  pelvic 
presentation :  here  too  interference  is  not  required  ;  on  the 
contrary  it  may  be  necessary  to  perform  podalic  version 
with  the  second  child.  And  when  a  uterus,  through  laxity 
of  its  walls  or  through  over-distension,  tends  to  cause  a 
pelvic  presentation,  here  too  this  presentation  is  best, 
because  when  the  head  is  the  advancing  part  it  is  apt  to  be 
forced  into  a  recess  in  the  lax  lower  uterine  segment,  so 
that  the  cervix  does  not  become  dilated,  and  podalic  version 
would  eventually  become  necessary.  And  even  when  the 
breech  j)i'esents  it  may  become  necessary  to  bring  down  a 
foot  for  the  same  reason,  or  because  the  breech  does  not 
enter  a  contracted  pelvis.  It  may  also  be  required  when 
there  is  prolapse  of  the  cord  or  placenta  praevia  and  the 
breech  is  still  movable,  in  order  to  save  the  child  and  not 
expose  the  mother  to  further  dangers. 

(h)  Preventive  treatment  for  cases  icJiere  patTiological  forms 
of  pelvis  or  other  typical  causes  have  produced  loresentations 
which  are  favourable  in  those  forms  of  pelvis  or  not  unfavour- 
aUe. 

When  describing  the  prophylactic  measures  required  for 
contracted  pelves  it  was  stated  that  obliquity  in  vertex 
presentations  was  favourable  in  a  flattened  pelvis,  and  that 
excessive  descent  of  the  occiput  was  desirable  in  generally 
contracted  and  certain  oblique  pelves.  Such  presentations 
I  include  in  this  group. 

When  the  sagittal  suture  enters  in  the  oblique  diameter, 
or  even  in  the  conjugate  of  the  brim,  nothing  should  be 
done  to  change  the  position,  especially  when  the  cause  of  it 
is  a  generally  contracted  or  a  lumbo-sacral  kyphotic  pelvis. 
Under  ordinary  circumstances  the  head  will  turn  into  the 

380 


PROPHYLAXIS   IN  MIDWIFERY 

transverse  diameter  at  the  brim  if  the  pains  are  strong  and 
the  patient  lies  on  the  side  towards  which  the  occiput  ought 
to  turn. 

Presentation  of  the  anterior  parietal  bone  or  Naegele's 
obliquity  is  the  most  favourable  presentation  in  flattened 
pelves,  and  it  should  not  be  interfered  with  unless  the 
deviation  is  extreme  and  the  sagittal  suture  remains 
stationary,  and  there  is  a  tendency  towards  an  ear  presenta- 
tion, or  unless  some  other  serious  symptom  appears,  such  as 
distension  of  the  lower  uterine  segment.  If  the  coexisting 
lateral  flexion  of  the  child's  body  is  too  great  because  of  a 
penduloiis  abdomen,  the  uterus  should  be  supported  and 
held  up  by  the  various  methods  already  described.  Naegele's 
obliquity,  which  often  occurs  at  the  onset  of  labour  under 
normal  conditions,  is  of  no  significance. 

Presentation  of  the  posterior  parietal  bone,  or  Litzmann's 
obliquity,  is  mu.ch  less  favourable  than  the  former,  and 
when  there  is  much  pelvic  contraction  leads  to  very  great 
difficulties.  The  case  should  be  very  carefully  watched, 
and  interference  will  be  required  according  to  the  table 
drawn  up  for  general  preventive  treatment  in  abnor- 
malities of  the  pelvis.  Two  additional  points  have  to  be 
considered  :  which  kind  of  pelvis  is  present  ?  and  does  the 
occiput  or  the  forehead  descend  most  under  the  influence  of 
the  pains  ?  The  latter  is  the  less  favourable  presentation, 
and  becomes  the  worse  according  to  the  degree  of  general 
contraction  of  the  pelvis  which  is  combined  with  the  flat- 
tened pelvis.  On  the  other  hand  a  combination  of  presenta- 
tion of  the  occipital  bone  and  of  the  posterior  parietal  bone 
affords  relatively  the  best  prognosis  for  generally-contracted 
pelves,  and  should  therefore  be  encouraged  as  a  preventive 
measure  by  suitable  posture  of  the  patient  and  by  pressing 
the  occiput  into  the  pelvic  brim. 

Descent  of  the  large  fontanelle  in  occipital  presentations 
and  in  obliquities  of  the  head  is  favourable  in  flattened 
pelves  and  unfavourable  in  generally-contracted  pelves.  In 
the  latter  the  presentation  should  be  corrected  by  internal 
and  external  manipulation  and  by  placing  the  patient  on 
the  side  corresponding  to  the  occiput. 

381 


THE   PREVENTION   OF  DISEASE 

Presentation  of  the  occiput,  or  Roederer's  obliquity,  is 
favourable  for  a  generally-contracted  pelvis  and  for  a  flat- 
tened generally-contracted  pelvis  when  combined  with 
Litzmann's  obliquity.  If  the  contraction  is  great  impaction 
readily  occurs.     For  this  see  "  Generally-contracted  Pelves," 

A  transverse  position  of  the  head  low  down  in  the  pelvis 
is  not  seldom  the  consequence  of  obliquities,  as  it  occurs  in 
fronto-anterior  presentations,  where  rotation  forwards  of 
the  occiput  commences  in  the  interspinous  line  but  is  not 
completed,  and  in  prolapse  of  the  anterior  arm,  in  inefEcient 
labour  pains  with  fronto-anterior  presentations,  in  funnel 
shaped  pelves  and  when  the  pelvis  is  too  wide  or  the  head 
too  small. 

If  then  the  presenting  part  of  the  vertex  is  already  near 
the  interspinous  line  and  there  is  no  rotation  forwards  of 
the  occiput  we  must  prevent  the  head  from  remaining  in 
this  transverse  position,  because  spontaneous  delivery 
would  be  very  difficult.  According  to  the  cause  we  must 
either  place  the  patient  on  the  side  corresponding  with  the 
occiput  (more  rarely  on  the  side  corresponding  with  the 
forehead,  when  the  presentation  was  originally  fronto- 
anterior),  or  else  rotate  forwards  the  small  fontanelle  (or  in 
certain  cases  the  large  fontanelle)  by  hand  or  by  the 
posterior  blade  of  the  forceps.  In  "  spontaneous  evolution  " 
and  in  delivering  ''  conduplicato  corpore  "  of  small  embryos 
in  transverse  presentations,  we  merely  assist  this  process  of 
delivery,  because  immature  and  macerated  embryos  can  be 
delivered  spontaneously  in  this  way.  Traction  on  the 
advancing  limb  will  help. 

(c)  Preventive  treatment  for  positions  and  presentations 
which  in  themselves  produce  difficulties. 

Fronto-anterior  presentations  with  descent  of  the  fore- 
head and  extension  of  the  head  occurs  when  the  resistance 
is  abnormal.  To  prevent  descent  of  the  forehead  the 
patient  should  be  placed  on  her  side,  the  side  corresponding 
with  the  foetal  occiput,  and  an  attempt  may  be  made  to  hold 
back  the  forehead  by  internal  manipulation.  If  this  fail 
and  the  brow  becomes  fixed  on  the  horizontal  ramus  of  the 
pubis,  the  head  should  be  extracted  with  forceps,  in  order 

382 


PROPHYLAXIS  IN  MIDWIFERY 

to  prevent  further  danger  to  mother  and  child.  This  is  in 
reality  a  preventive  measure,  seeing  that  the  brow  must 
first  be  pushed  up  from  its  fixed  position  on  the  pelvic  ramus 
and  rotated  into  the  transverse  diameter  and  afterwards 
extracted.  If  the  child  is  dead  it  is  better  for  the  mother's 
sake  to  perforate  and  extract  with  craniotomy  forceps. 

Brow  and  face  presentations  are  aetiologically  closely 
related  ;  in  the  former  the  prognosis  is  generally  bad  ;  in 
the  latter,  when  the  chin  remains  posterior,  the  prognosis 
is  invariably  bad.  It  is  therefore  urgent  that  these 
presentations  should  be  prevented  or  should  be  converted 
into  more  favourable  ones.  These  unfavourable  presenta- 
tions may  be  produced  by  abnormal  resistance  and  by 
functional  abnormalities.  On  the  part  of  the  mother  they 
may  arise  from  the  pelvis,  from  the  soft  parts,  or  from  the 
nature  of  the  labour  pains,  and  from  incorrect  posture  or 
restlessness.  On  the  side  of  the  embryo,  they  may  arise 
from  too  great  or  too  little  rigidity,  from  faulty  position 
through  prolapse  of  an  arm,  from  twins,  from  hydramnios, 
or  from  placenta  praevia.  A  short  umbilical  cord  twisted 
round  the  neck,  or  incorrect  operative  interference,  such 
as  traction  with  forceps  in  the  wrong  direction,  may  also 
give  rise  to  them. 

All  the  above  named  causes  must  be  met  and  treated 
according  to  the  rules  already  given.  "When  the  brow 
or  face  begins  to  come  down,  or  when  these  presentations 
already  exist  and  the  head  is  still  movable,  they  should 
be  converted  into  occipital  presentations  bimanually  by 
the  combined  action  of  external  and  internal  manipulations. 
Should  this  method  fail,  or  if  we  anticipate  danger  either 
immediately  or  later  from  a  vertex  presentation,  podalic 
version  should  be  performed  as  a  prophylactic  measure. 
But  even  when  the  head  is  already  low  in  the  pelvic,  brow 
presentations  and  mento-posterior  face  presentations  can 
still  be  manually  converted  into  mento  -  anterior  face 
presentations.  These  are  however  more  difficult  to  correct 
than  when  the  head  is  movable,  and  if  the  attempt  is  not 
successful  we  have  then  only  to  consider  the  safety  of  the 
mother.    No  attempt  should  generally  be  made  with  forceps, 

383 


THE  PEEVENTION  OE  DISEASE 

because  tlie  mother  is  thereby  exposed  to  serious  injuries, 
and  the  child  too — and  a  successful  issue  is  more  than 
doubtful  from  the  very  beginning. 

Presentations  of  the  anterior  or  posterior  ear  are  unfavour- 
able extreme  results  of  presentations  of  the  anterior  or 
posterior  parietal  bones,  and  what  was  said  under  the 
latter  applies  still  more  here. 

In  pelvic  presentations,  the  unfavourable  are  presentation 
of  the  foot,  lateral  lodgment  of  the  breech,  a  catching  of 
the  after-coming  head  on  the  symphysis  by  the  brow  or 
chin,  and  fixation  of  the  anterior  arm  [in  the  nape  of  the 
neck  behind  the  occiput. 

"When  the  breech  has  become  lodged  in  the  iliac  fossa, 
and  when  there  is  incomplete  presentation  of  the  posterior 
foot,  the  anterior  leg  should  be  brought  down.  It  should 
be  borne  in  mind  that  the  os  uteri  is  incompletely  dilated 
in  foot  presentations,  and  incision  of  the  os  may  be 
needed.  Above  all,  it  is  best  to  wait  as  long  as  possible 
before  extracting,  unless  examination  of  the  heart-sounds 
shows  it  to  be  necessary. 

When  abnormal  rotation  of  the  after-coming  head  has 
been  diagnosed — that  is  when  the  occiput  is  posterior — and 
the  breech  is  still  movable,  it  is  possible  at  once  to  act  so 
as  to  prevent  difficulties  which  would  later  arise.  Thus, 
if  in  spite  of  good  labour  pains  and  dilatation  of  the  os 
uteri  rotation  has  not  taken  place,  the  anterior  foot  should 
be  brought  down.  If  the  breech  is  fixed  and  high,  a  loop 
should  be  passed  round  the  groin  of  the  anterior  thigh,  and 
traction  be  made  in  a  direction  from  the  side  towards  the 
front.  Should  the  breech  be  fixed  but  already  low  in  the 
pelvis,  rotation  of  the  trunk  is  effected  by  the  index  finger 
in  the  groin  with  the  help  of  the  thumb  and  middle  finger, 
while  with  the  other  hand  upon  the  abdomen  the  head  is 
brought  into  the  transverse  diameter  and  then  is  pressed 
through  the  brim  of  the  pelvis  by  pressing  on  the  forehead. 
If  the  head  is  already  in  the  pelvis,  it  can  be  brought  into 
the  transverse  diameter  by  the  finger  in  the  mouth  and  the 
occiput  be  rotated  forwards.  When  this  fails,  with  dead 
children,  a  blunt  hook  can  be  inserted  in  the  canine  fossa  to 

384 


PROPHYLAXIS  IN  MIDWIFERY 

make  traction.  Then  the  finger  being  placed  in  the  mouth 
and  the  shoulders  grasped  from  behind,  the  occiput  is  guided 
over  the  perineum  while  the  face  is  fixed  against  the  pubic 
symphysis. 

Extension  of  the  arms,  which  makes  it  possible  for 
the  anterior  arm  to  become  fixed  behind  the  head,  can 
be  avoided  by  extracting  the  child  slowly  and  only 
during  a  pain  ;  or  the  labour  pains  may  be  replaced  by  the 
strong  pressure  of  two  hands  upon  the  fundus  uteri. 

The  preventive  treatment  for  oblique  and  transverse 
presentations  (shoulder  presentations)  depends  largely  upon 
the  causes  which  have  produced  them,  and  which  may  in 
brief  be  summed  up  as  abnormally  increased  or  diminished 
resistances  during  childbirth. 

There  may  have  been  faulty  posture  or  sudden  violent 
movements  on  the  part  of  the  mother.  The  pelvic  inlet 
may  have  been  contracted.  The  uterus  may  have  been 
too  broad  or  its  walls  too  lax,  especially  in  multiparae,  or 
the  uterus  may  have  been  abnormal  in  shape  or  in  position, 
as  in  anteflexion.  The  labour  pains  may  have  been 
anomalous.  The  ovum  may  have  been  in  fault,  as  in 
placenta  praevia,  hydramnios,  or  premature  rupture  of  the 
membranes.  The  child  may  have  been  too  large  or  too 
small  or  hydrocephalic,  or  twins  may  have  been  present. 

Many  of  these  primary  causes  may  be  removed  or 
rendered  harmless  during  pregnancy  and  during  labour 
by  the  methods  already  described. 

If  at  the  onset  of  labour  an  oblique  position  has  been 
diagnosed,  it  is  generally  possible  to  restore  the  vertical 
position  when  the  pains  become  stronger,  if  other  circum- 
stances are  favourable.  The  patient  should  be  placed  in 
the  lateral  position,  on  the  side  towards  which  the  child's 
head  tends,  and  in  this  way  we  can  help  to  convert  it  into 
a  vertex  presentation. 

The  oblique  presentation  may  be  corrected  by  external 
manipulation  when  the  presenting  part  (shoulder)  is  not 
already  fixed  in  the  pelvis  and  the  membranes  are  still 
intact ;  it  may  be  done  even  when  the  os  uteri  is  almost 
completely  dilated. 

386  c  0 


THE   PREVENTION  OF  DISEASE 

When  combined  internal  version  is  required,  though  only- 
two  or  three  fingers  are  employed  in  Braxton  Hicks'  method, 
it  is  preferable  as  a  prophylactic  measure  to  perform  podalic 
rather  than  cephalic  version,  even  in  those  cases  where 
podalic  version  is  not  indicated  so  far  as  the  primary  cause 
of  the  oblique  position  is  concerned. 

When  "  spontaneous  version  "  has  taken  place  in  the  pelvis, 
or  "  spontaneous  evolution  "  or  "  spontaneous  expulsion,"  in 
the  former  two,  the  prognosis  is  good  for  the  child  in  only 
one-seventh  of  all  cases,  and  is  doubtful  as  regards  the  mother ; 
but  in  spontaneous  expulsion  the  prognosis  is  bad  for  the 
child,  and  very  serious  as  regards  the  mother.  These  cases 
may  become  "  neglected  transverse  presentations,"  and 
the  many  serious  consequences  resulting  from  the  protracted 
labour  and  the  treatment  of  these  has  already  been  described 
under  "  Rupture  of  the  Uterus  "  and  "  The  General  Treat- 
ment of  Anomalies  of  the  Pelvis."  The  primary  condition 
for  success  is  to  keep  the  membranes  intact  as  long  as 
possible,  and  to  retain  the  liquor  amnii.  Premature 
separation  of  the  placenta  is  one  of  the  dangers. 

8.  PEEVENTIVE  TEEATMENT  FOE  DIFFICULTIES  IN 
LABOUE  CAUSED  BY  THE  FOETUS 

(a)   Twin  pregnancies  and  multiple  pregnancies. 

Pelvic  presentations,  oblique  presentations,  and  the  more 
unfavourable  presentations  are  far  more  frequent  in  twin 
and  in  multiple  pregnancies  than  in  single  pregnancies. 
Sometimes  the  second  placenta  is  separated  before  the  birth 
of  the  second  child,  and  very  rapid  extraction  can  alone 
save  the  second  child  from  asphyxia. 

As  a  result  of  over-distension  and  atony  of  the  uterus, 
post-partum  haemorrhage  is  to  be  feared ;  ergot  should  be 
given  as  a  preventive  measure  shortly  before  the  expulsion 
of  the  second  child,  and  the  uterus  must  be  carefully 
watched.  The  placental  end  of  the  umbilical  cord  of  the 
firstborn  child  should  always  be  ligatured  to  prevent  loss 
of  blood  by  the  second  child  through  placental  anastomoses. 

386 


PROPHYLAXIS   IN  MIDWIFERY 

(b)  Malformations. 

Difficulties  seldom  arise  because  a  foetus  is  premature  or 
poorly  developed.  Difficulties,  even  rupture  of  the  uterus, 
may  arise  most  frequently  from  hydroceplialus  and  from 
distension  of  the  abdomen  of  the  foetus  by  hydronephrosis 
or  ascites.  These  are  often  combined  with  hydramnios. 
Pelvic  presentations  are  very  common.  In  a  fourth  of  all 
cases  spontaneous  delivery  occurs  by  the  hydrocephalic  head 
being  squeezed  through  with  a  vertex  presentation.  This 
should  be  promoted,  and  puncture  of  the  vertex  is  most 
rational.  For  the  same  reason,  diminution  in  size  of  the 
abdomen  of  a  foetus  which  in  any  case  cannot  live,  can  be 
effected  by  means  of  Sie hold's  scissors. 

The  results  of  the  delivery  of  excessively  large  foetuses, 
or  those  with  much  ossified  skulls  or  abnormally  broad 
shoulders  are  very  serious.  One  should  not  wait  too  long. 
To  deliver  the  shoulders,  division  of  one  clavicle  is  recom- 
mended. 

9.  PREVENTIVE  TREATMENT   FOR   DIFFICULTIES  ARISING- 
FROM  THE  UMBILICAL  CORD  OR  MEMBRANES 

Prolapse  of  the  cord  greatly  endangers  the  life  of  the 
child,  and  attempts  should  be  made  to  replace  it  even  when 
the  OS  uteri  is  insufficiently  dilated.  It  is  safest  to  perform 
podalic  version  either  immediately,  according  to  Braxton 
Hicks'  method,  or  after  complete  dilatation  of  the  os  uteri 
by  a  hydrostatic  dilator  which  serves  to  dilate  the  os  and 
at  the  same  time  to  hold  back  the  umbilical  cord.  Under 
"  Preventive  Treatment  in  Occipital  Presentations  "  I  have 
already  referred  to  twisting  of  the  cord  round  the  neck. 

Intra-uterine  placental  haemorrhage  may  be  caused  by 
many  conditions.  Placenta  praevia  or  insertio  velamentosa 
may  give  rise  to  it,  or  it  may  result  from  premature  separa- 
tion of  the  placenta  or  its  partial  adhesion,  by  its  retention, 
or  by  atony  of  the  site  from  which  it  has  come. 

In  insertio  velamentosa  we  must  guard  against  injuring 
any  vessel  on  the  membrane  when  the  membranes  are 
artificially  ruptured,  and  we  must  in  most  cases  attempt  to 

387 


THE  PREVENTION   OF  DISEASE 

keep  the  bag  of  membranes  entire  till  the  os  uteri  is  com- 
pletely dilated,  and  then  immediately  proceed  with  the 
extraction  of  the  foetus. 

Premature  separation  of  the  placenta  may  arise  from 
nephritis,  eclampsia,  infective  diseases,  from  all  causes  which 
produce  abortion,  from  trauma,  too  long  delayed  rupture  of 
tough  membranes,  and  from  excessive  labour  pains.  These  are 
for  the  most  part  causes  which  can  be  successfully  removed 
if  diagnosed  in  time.  If  the  placenta  has  become  pre- 
maturely detached,  the  mother  runs  great  danger  from 
haemorrhage  and  the  child's  life  is  certainly  lost.  For 
these  reasons  delivery  should  be  immediately  brought 
about. 

Post-partum  haemorrhage  through  atony  of  the  uterus 
may  be  the  consequence  of  inflammatory  processes,  of 
which  the  fibrous  adhesion  of  the  placenta  is  a  sign,  or  it 
may  be  the  result  of  disturbances  in  innervation,  especially 
after  an  exhausting  labour,  or  over-distension  in  pregnancy, 
or  after  precipitate  labour.  In  multiple  myomata  of  the 
uterus  it  is  impossible  for  the  uterine  wall  to  contract 
evenly. 

In  the  last  two  groups  the  atony  is  known  to  exist,  and 
ergot  should  be  given  as  a  preventive  measure  shortly 
before  the  expulsion  of  the  child's  head.  The  placenta 
should  then  not  be  expressed  too  early,  unless  there  is  some 
special  indication  for  it,  but  we  should  rather  wait  for  a 
few  hours.  When  expressing  the  placenta  by  Crede's 
method  the  fundus  uteri  must  be  firmly  contracted,  other- 
wise inversion  of  the  uterus  is  apt  to  occur,  as  it  would  if 
the  cord  were  pulled  upon.  If  after  expulsion  of  the 
placenta  the  uterus  disappears  from  beneath  the  fingers 
and  kneading  of  the  soft  walls  of  the  uterus  does  not 
restore  it,  the  uterus  must  be  massaged  bimanually ;  or 
lastly,  the  vaginal  portion  of  the  cervix  must  be  drawn 
down  to  the  vulva  by  vulsellum  forceps. 

When  part  of  the  placenta  is  retained  or  the  placenta  is 
adherent  by  one  edge,  it  must  be  removed  by  hand  to 
prevent  haemorrhage,  decomposition  and  sepsis.  The 
strictest  asepsis  and  the  greatest  care  must  be  observed  lest 

388 


PROPHYLAXIS  IN  MIDWIFERY 

a  fatal  injury  or  infection  should  be  caused.  The  uterus 
must  be  firm,  so  that  the  remains  of  the  placenta  can  be 
distinguished  from  the  uterine  wall.  After  the  operation 
ergot  should  be  administered  and  the  uterus  should  be 
irrigated  with  a  hot  antiseptic  solution  such  as  a  1  or  2  per 
cent,  solution  of  lysol,  but  corrosive  sublimate  must  not  be 
used.  In  every  case  of  post-partum  haemorrhage  the 
possibility  of  lacerations  of  the  cervix  or  vagina  should  be 
borne  in  mind,  should  be  looked  for  through  a  speculum, 
and  be  sutured. 

10.  PREVENTIVE  TREATMENT  FOR  ANOMALIES  IN 
THE  LABOUR  PAINS 

"We  have  already  repeatedly  emphasized  the  importance 
of  regulating  the  labour  pains  as  a  preventive  measure. 
Excessive  labour  pains  lead  to  precipitate  birth  when  the 
resistance  offered  by  the  maternal  parts  is  slight,  as  in 
multiparae.  Heredity  or  too  short  an  umbilical  cord  may 
also  play  a  part  in  bringing  about  precipitate  labour. 
Prophylactic  treatment  will  prevent  harm  occurring.  The 
patient  should  early  assume  the  recumbent  posture,  lying 
on  her  side,  and  should  not  make  any  bearing  down  efforts. 
The  perineum  must  be  supported  early. 

Labour  pains  which  are  progressively  stronger  and 
stronger  and  yet  cannot  overcome  the  obstruction  lead  to 
tumultuous  pains,  and  finally  to  tetanic  contraction  of  the 
uterus.  These  pains  cause  no  advance  of  the  foetus,  but 
seriously  predispose  the  uterus  to  rupture.  Further,  they 
give  rise  to  premature  separation  of  the  placenta  and  to 
danger  of  death  of  the  mother  from  haemorrhage  ;  and 
lastly,  this,  combined  with  the  interruption  of  the  placental 
circulation  by  the  long  continued  uterine  contractions,  may 
cause  death  of  the  child.  Unsuitable  and  therefore  unsuc- 
cessful attempts  at  delivery  and  the  administration  of  large 
doses  of  ergot  during  the  first  stage  must  be  altogether 
avoided. 

An  anaesthetic  should  be  given  to  moderate  the  labour 
pains,  and  delivery  should  be  completed  under  anaesthesia, 
generally  by  reducing  the  size  of  the  foetus.     It  should  be 

389 


THE  PREVENTION  OE  DISEASE 

remembered  that  prolonged  narcosis  is  injurious,  as  it 
increases  the  danger  of  infection  in  women  who  are  already 
exhausted,  and  often  does  not  remove  the  spasm  of  the 
uterus.  Version  is  always  contra-indicated  in  such  cases  of 
neglected  transverse  presentations. 

Spasmodic  strictures  of  the  uterus  are  rare  in  labour. 
Cases  which  are  often  regarded  as  such  represent  local 
uterine  contractions  which  do  not  effectively  dilate  the 
cervix.  Spasmodic  strictures  may  however  be  observed  in 
the  third  stage  of  labour,  and  lead  to  retention  of  the 
placenta  and  haemorrhage ;  one  edge  of  the  placenta  is 
found  to  be  presenting  at  the  os  uteri.  Preventive  treat- 
ment consists  in  great  caution  in  the  use  of  ergot ;  some- 
times indeed  it  regulates  the  labour  pains  and  brings  about 
a  separation  of  the  rest  of  the  placenta,  but  it  may  also 
increase  the  spasm  by  which  the  placenta  has  become 
constricted.  Great  caution  must  be  observed  also  with 
narcotics,  because  of  post  partum  haemorrhage.  Premature 
attempts  at  expression  of  the  placenta  after  the  expulsion 
of  the  child  readily  call  forth  such  conditions  ;  no  advantage 
is  ever  gained  by  such  haste.  If  there  is  no  haemorrhage 
we  may  wait  for  hours,  or  even  half  a  day,  applying  hot 
compresses,  promoting  diaphoresis,  and  endeavouring  to 
procure  sleep  for  the  patient,  who  should  of  course  be 
watched.  The  placenta  may  then  be  expressed  by  Crede's 
method,  or  if  this  fails  must  be  extracted  by  hand. 

Partial  spasmodic  labour  pains  occur  frequently  in  nervous 
chlorotic  patients.  They  are  ineffectual  because  they  do 
not  perfectly  direct  the  long  axis  of  the  child  towards  the 
internal  os  uteri,  because  they  drive  the  head  into  a  recess 
of  the  lower  uterine  segment  when  the  latter  is  lax,  and 
because  later  their  painfulness  prevents  the  proper  use 
of  bearing  down  efforts.  The  primary  causes  may  be 
chronic  inflammations  or  disturbances  in  innervation ;  or 
when  there  is  hyperaesthesia  of  the  vaginal  vault  or  of  the 
cervix,  they  may  be  caused  by  digital  examination.  In 
such  j)atients  an  internal  examination  should  therefore 
be  made  only  when  there  is  urgent  necessity  for  it. 

The  labour  pains  should  be  regulated  and  their  effects 

390 


PROPHYLAXIS  IN  MIDWIFERY 

controlled  by  narcotics,  or  by  baths,  hot  compresses,  or  a 
mustard  leaf. 

The  author  regards  the  promoting  of  diaphoresis  as 
an  excellent  method  of  regulating  the  pains.  If  it  does 
not  succeed  podalic  version  may  be  required  when,  after 
dilatation  by  a  hydrostatic  dilator,  the  head  does  not 
present. 

True  weakness  of  the  labour  pains,  which  is  not 
produced  by  tetanic  uterine  spasm,  is  seldom  met  with.  It 
may  be  produced  by  many  different  causes,  which  should 
be  known  in  order  that  they  may  be  successfully  over- 
come by  preventive  treatment.  The  danger  begins  with 
the  early  rupture  of  the  membranes,  which  allows  the 
uterine  cavity  to  become  invaded  by  cocci,  and  causes  death 
of  the  child  through  the  prolonged  labour.  This  however 
is  true  only  for  certain  forms  of  weakness  of  the  labour 
pains,  which  may  be  grouped  together  as  secondary  causes. 
The  primary  causes  are  the  previous  over-distension  of  the 
uterus  by  hydramnios  and  twins,  the  exhaustion  of  the 
uterus  by  a  protracted  labour  or  haemorrhage,  chronic 
inflammations,  adhesions  of  the  uterus  to  other  structures, 
and  faulty  inclination  of  the  uterus.  Indirect  weakness 
of  labour  pains  is  produced  by  inefHcient  action  of  the 
abdominal  muscles,  by  an  overfilled  bladder  or  rectum,  and 
by  pelvic  inflammations. 

The  knowledge  of  the  causes  enables  us  to  remove  or  to 
reduce  them  to  some  extent;  or  if  they  are  already  acting^ 
it  leads  us  to  shorten  the  labour  as  far  as  possible,  and  to 
take  all  due  care,  especially  in  the  third  stage  of  labour 
which  should  not  be  too  actively  treated.  Ergot  may 
sometimes  be  given  as  a  preventive.  Primary  weakness  of 
the  labour  pains  may  be  due  to  general  bodily  weakness,  or 
to  weakness  of  the  uterine  walls  when  the  uterus  is  ill 
developed  or  contains  tumours.  It  occurs  also  from  a  want 
of  contractility  in  older  patients,  which  results  from  sub- 
involution. This  weakness  of  the  labour  pains  may  be 
prevented  by  rest,  by  keeping  the  membranes  unruptured 
as  long  as  possible,  and  by  rupturing  them  after  the  os  uteri 
is  completely  dilated.     The  labour  pains  should  be  stimu- 

391 


THE  PREVENTION   OF  DISEASE 

lated  by  warm  baths   or   by   bot   vaginal   doucbes,    at   a 

temperature  of  108°  to  117°  F.   every   one  or  two  hours, 

using   each  time   one  or  two  gallons    of    sterilized  "8   per 

cent,  saline  solution,  or  a  quarter  per  cent,  solution  of  lysol. 

The  fluid  must  be  injected  under  a  very  low  pressure.     Hot 

compresses  over   the   fundus    of    the   uterus   may  also  be 

employed,  diaphoresis  should  be  promoted,  and  stimulants, 

especially  broth  and  tea,  are  useful.     Narcotics  must  not  be 

used  till  towards  the  end  of   the  second  stage  of  labour. 

Do  not  forget  to  empty  the  urinary  bladder  and  rectum. 

If    the  uterus  is  over-distended  rupture  the  membranes. 

In  other  cases  hydrostatic  dilators  of  the  cervix  and  vagina 

may  be  employed.     The  various  methods  of  expression  and 

of  extraction   may   have   to   be  considered,  and  should  be 

selected  strictly  in  accordance  with  the  indications.     They 

should  be  slowly  carried  out  in  conjunction  with  the  labour 

pains,  and  the  simplest  methods  should  be  first  tried.     The 

third  stage  of  labour  must  be  treated  in  the  way  already 

described.     A  very  rare  consequence  of  relaxation  of  the 

cervix  is  acute  inversion  of  the  uterus,  already  referred  to 

in  the  G-ynaecological  section.     Therefore,   pulling  on  the 

umbilical  cord  and  expression  of    the   placenta  when  the 

uterus  is  not  firmly  contracted,  are  strictly  contra-indicated. 

11.  PEEVENTIVE  TEEATMENT  FOE  DIFFICULTIES  AEISINQ 
FEOM  DISEASE  OF  OTHEE  OEQANS 

The  most  important  of  these  are  disease  of  the  heart, 
disease  of  the  lungs,  such  as  pneumonia,  influenza,  and 
especially  tuberculosis,  chronic  nephritis  (with  eclampsia)  and 
erysipelas,  which  readily  leads  on  to  puerperal  fever.  When 
cardiac  lesions  are  present,  the  heart  action  is  injuriously 
affected  by  labour  and  by  the  circulatory  changes  accom- 
panying it,  especially  in  the  abdominal  region.  This  can 
be  prevented  by  securing  cardiac  compensation  during 
pregnancy.  The  membranes  should  be  ruptured  early, 
injections  and  inhalations  of  ether  should  be  given  during 
and  after  parturition,  sand  bags  should  be  placed  on  the 
abdomen  after  delivery,  and  delivery  may  even  be 
accelerated  by  a  hydrostatic  dilator  and  extraction,  which 

392 


PROPHYLAXIS  IN   MIDWIFERY 

should  be  very  slowly  performed.  Some  liaemorrliage 
post  partum  is  not  altogether  unfavourable.  Ergot  is 
injurious.  Oedema  of  the  lungs  readily  sets  in,  both  in 
pulmonary  and  in  cardiac  disease.  "With  tuberculosis  there 
is  a  rapid  loss  of  strength  by  progress  of  the  disease,  and 
this  is  aggravated  by  severe  haemorrhage.  The  latter 
should  be  prevented,  and  symptoms  treated. 

The  preventive  treatment  of  eclampsia  has  already  been 
given.  When  the  pulse  is  bad,  narcotics,  and  especially 
chloroform,  should  be  avoided  as  much  as  possible. 

12.    PREVENTIVE  TREA.TMENT  IN  OBSTETRIC  PRO- 
CEDURES 

General  prophylactic  measures  against  puerperal  infec- 
tion are  assumed  to  be  known  in  every  detail  to  the 
obstetric  practitioner.  There  must  be  no  contact  with  any 
septic  person  or  thing.  There  must  be  the  most  minute 
mechanical  and  chemical  purity,  and  for  this  purpose 
Mikulicz  recommends  the  spiritus  saponatus  of  the  German 
Pharmacopoeia.  No  vaginal  examinations,  or  as  few  as 
possible,  should  be  made.  No  operative  interferences  should 
be  undertaken  except  according  to  the  indications.  These 
are  the  principles.  Antiseptics,  at  the  head  of  which  are 
cresol  and  lysol,  must  be  very  sparingly  used  in  the  genital 
canal.  In  private  practice  we  need  not  as  a  routine 
principle  carry  out  a  vaginal  antisepsis,  nor  yet  under  all 
circumstances  refrain  from  using  it.  If  required,  as  before 
and  after  operative  interference,  or  versions,  or  when  one 
is  doubtful  of  the  aseptic  conditions  of  previous  examina- 
tions, the  physician  himself  should,  at  least  once,  give  the 
antiseptic  douche,  and  then  entrust  it  to  a  trained  and 
conscientious  nurse.  It  is  sometimes  advisable  first  to 
inspect  the  irrigator  tubes  and  nozzle  and  see  how  the 
nurse  uses  them.  Under  the  preventive  treatment  of 
operative  interference  are  included  the  most  careful 
examination,  and  diagnosis  of  the  presentation,  and  for 
this  purpose  the  bladder  and  rectum  should  previously 
have  been  emptied. 

Operations  intended  to  improve  the  presentation,  turn- 

393 


THE   PREVENTION  OF   DISEASE 

ing  and  the  reposition  of  prolapsed  parts,  should  not  be 
undertaken  when  the  lower  uterine  segment  is  tensely  dis- 
tended and  the  contraction  ring  is  approaching  the  umbili- 
cus. Further,  they  shou.ld  not  be  undertaken  when  the 
head  has  passed  the  pelvic  brim  and  is  fixed  in  the  pelvis. 
To  prevent  a  threatened  prolapse  of  a  hand  or  foot  or  of  the 
cord,  the  bag  of  membranes  should  be  kept  intact  as  long 
as  possible,  the  patient  be  at  once  placed  in  the  recumbent 
posture,  on  the  side  towards  which  the  presenting  part  of 
the  child  has  shifted,  or  lastly  should  assume  the  knee- 
elbow  position.  Early  bearing  down  efforts  should  be 
forbidden.  When  the  prolapsed  part  has  been  successfully 
replaced,  the  presenting  head  should  be  firmly  pressed 
down  into  the  pelvic  brim  so  that  the  replaced  part  cannot 
descend. 

These  operative  procedures  may  only  be  used  to  reinstate 
the  vertex  presentation  when  there  is  no  immediate  danger, 
and  when  presumably  no  further  obstacle  is  present,  other- 
wise by  podalic  version  we  make  it  possible  to  deliver  at 
any  moment  when  the  os  uteri  is  sufficiently  dilated.  The 
anterior  foot  should  be  used  to  turn,  because  the  back  of 
the  child  is  thereby  brought  to  the  front,  or  remains  in 
front.  In  oblique  presentations  the  advancing  foot  should 
be  brought  down,  and  when  the  back  of  the  child  is  directed 
posteriorly,  the  version  should  be  completed  by  bringing 
down  the  upper  foot,  that  is,  after  the  lower  foot  has  been 
brought  down  and  left  in  the  vagina  to  fix  the  child.  The 
liquor  amnii  may  be  allowed  to  escape  early,  so  that  the 
head  may  become  fixed  after  the  version. 

"When  it  is  desired  to  puncture  the  membranes,  but  to 
retain  the  liquor  amnii  if  possible,  the  membranes  should 
be  perforated  as  high  up  as  possible  above  the  internal  os 
uteri.  The  patient  should  afterwards  lie  still  in  the  dorsal 
position.  The  membranes  may  similarly  be  punctured  in 
the  second  stage  of  labour,  when  the  membranes  are  very 
tough  and  the  placental  site  is  being  pulled  upon.  Here 
too  care  must  be  taken  not  to  injure  any  placental  vessels 
on  the  membranes  (insertio  velamentosa),  which  might 
cause  death  of  the  child  by  loss  of  blood.     Puncture  of  the 

394 


PROPHYLAXIS   IN   MIDWIFERY 

membranes  is  a  preventive  measure  against  the  possibility 
of  premature  separation  of  tbe  placenta  and  concealed 
haemorrhage. 

In  perforation  the  head  must  be  fixed  from  above ;  for 
perforation  of  the  after-coming  head  one  selects  the 
posterior  temporal  fontanelle.  When  applying  the  cranio- 
clast,  no  maternal  soft  parts  or  foetal  membranes  should  be 
included.  If  the  sharp  hook  is  used  in  the  extraction,  it 
must  be  well  protected  and  firmly  fixed  so  that  it  may 
not  slip  off  and  cause  serious  injury.  In  performing 
embryotomy  never  divide  or  grasp  anything  which  cannot 
be  well  included  within  the  two  examining  fingers  and 
its  nature  diagnosed. 

Delivery  by  expression  is  the  operation  which  is  least 
injurious  and  dangerous,  because  the  internal  genitalia  are 
not  interfered  with.  But  Crede's  expression  of  the  placenta 
must  not  be  adopted  too  soon,  not  before  expiration  of  half 
an  hour  after  the  birth  of  the  child,  and  not  during  an 
interval  between  two  pains,  or  it  may  cause  inversion  of 
the  uterus. 

In  pelvic  presentations  the  following  points  must  be 
observed  in  the  extraction  of  the  child.  The  back  of  the 
child  should  be  brought  to  the  front,  the  traction  must  be 
slowly  made,  and  not  in  the  intervals  between  the  pains ; 
the  mistake  should  not  be  made  of  trying  to  bring  down 
the  legs  too  soon.  The  head,  the  face  being  directed  back- 
ward, should  not  be  drawn  into  the  cervical  canal  till  the 
latter  is  sufficiently  dilated.  The  umbilical  cord  should  be 
put  back  when  the  child  "  rides  "  upon  it.  The  arms  must 
not  be  permitted  to  become  extended  by  too  rapid  traction 
during  the  intervals  between  the  pains,  but  pressure  should 
also  be  made  upon  the  fundus  of  the  uterus  externally. 
The  arms  should  be  brought  down  in  a  curve  over  the  face 
and  chest.  The  anterior  arm  should  only  be  brought 
straight  down  when  the  elbow  presents.  Great  care 
must  be  taken  when  extracting  the  head  and  protecting 
the  perineum,  because  too  strong  a  traction  or  levering 
may  cause  serious  tension  on  the  cervical  muscles,  and 
even   lacerations   of   the   vertebral  column.      The   method 

395 


THE   PREVENTION   OF  DISEASE 

may  be  modified  by  placing  tlie  index  and  ring  fijigers  over 
tbe  shoulders  of  the  child,  the  middle  finger  stretched 
towards  the  occiput,  the  other  index  fijiger  and  possibly 
also  the  middle  finger  is  placed  in  the  mouth,  and  the 
thumb  outside  against  the  lower  jaw. 

Forceps  may  only  be  applied,  as  was  stated  under 
"  version,"  when  the  head  is  firmly  fixed,  the  os  uteri  fully 
dilated,  the  membranes  ruptured,  and  the  child  alive.  The 
contraction  of  the  pelvis  must  not  be  greater  than  indicated 
in  the  table  given  above,  p.  365.  Pressure  upon  the  foetal 
skull  and  pendulum  movements  from  above  downwards  are 
not  permissible.  When  applying  forceps,  and  with  the  first 
trial  traction,  we  must  be  sure  that  no  maternal  soft 
parts  or  foetal  membranes  or  parts  of  the  child  have  been 
included,  and  that  the  head  is  following  as  traction  is  made, 
and  is  rotating  correctly.  Traction  should  be  slow  and 
steady,  and  should  be  made  only  during  the  pains.  The 
forceps  must  be  applied  so  that  the  concavity  of  their 
pelvic  curve  is  directed  forwards  and  turned  towards 
the  part  presenting.  If  the  head  does  not  rotate 
sufficiently,  the  blades  of  the  forceps  should  be  re- 
moved and  re-a]3plied  in  the  transverse  or  obhque  diameter. 
The  forceps  should  be  removed  before  the  head  passes  over 
the  perineum,  and  the  four  fingers  should  protect  the 
perineum  while  the  thumb  holds  back  the  head.  A  lateral 
incision  should  be  made  if  the  vulval  orifice  is  too  small. 
Forceps  are  indicated  for  the  after-coming  head  when 
manual  traction  to  overcome  the  resistance  would  be  danger- 
ous for  the  child.  They  should  never  be  used  when  the 
head  is  still  high.  In  funnel  shaped  pelvis  a  transverse 
diameter  of  about  three  inches  is  the  limit  within  which  it 
is  possible  to  extract  by  forceps. 

Preventive  treatment  as  regards  surgical  measures  to 
bring  about  delivery  consists  essentially  in  their  limitation 
both  in  frequency  and  in  extent.  They  are  in  reality 
wounds  and  are  exposed  to  contact  with  lochial  discharge, 
especially  in  protracted  and  so-called  "  dry  "  labours,  so  that 
the  conditions  for  healing  are  far  more  unfavourable  than 
in  gynaecological  operations.     During  the  first  few  months 

396 


PEOPHYLAXIS   IN   MIDWIFERY 

after  delivery  and  when  the  patient  suckles  her  child,  it  is 
very  difficult,  and  may  be  impossible,  to  persuade  her  to 
undergo  an  operation  which  will  confine  her  to  bed, 
and  unless  primary  union  has  taken  place,  the  defects 
remain  until  the  appearance  of  other  symptoms  demands 
treatment.  Lateral  incisions  into  the  perineum  should  be 
especially  considered  in  this  respect,  the  very  limited 
indications  for  which  I  have  already  given  under  "  Vertex 
Presentations  "  ;  they  heal  far  less  readily  than  perineal 
lacerations  of  the  second  degree.  In  suturing,  the  deeper 
parts  of  the  opposed  raw  surfaces  of  the  levator  ani  muscle 
must  be  closely  approximated.  In  deep  vagino-perineal 
incisions,  haemorrhage  is  severe  and  must  be  stopped  by 
clip  forceps  till  delivery  is  completed.  Healing  of  the 
wound  is  best  aided  by  letting  lotion  run  over  it  frequently, 
by  sprinkling  with  airol,  and  by  keeping  it  at  rest. 
The  choice  of  ligature  is  immaterial,  but  non-absorbent 
ligatures  are  preferable.  The  superficial  crucial  incisions 
of  the  OS  uteri  should  not  be  stitched,  but  if  fever  sets  in 
they  should  be  examined  through  the  speculum,  and  if 
necessary  be  cauterized  and  irrigated  with  creosol  or  lysol 
solution  under  slight  pressure.  Deep  incisions  into  the 
vaginal  tissues  must  be  sutured. 

Preventive  treatment  in  Caesarian  section  consists  first 
in  performing  it  at  the  right  moment.  Veit  defines  the 
right  time  as  that  when  the  genital  canal  is  still  aseptic, 
the  bag  of  membranes  entire,  and  when  labour  pains  have 
already  set  in.  Infection  and  post  partum  haemorrhage 
are  thereby  obviated.  For  the  prevention  of  haemorrhage, 
a  large  dose  of  ergotin  is  given  hypodermically  after 
removal  of  the  placenta,  and  ergot  is  again  subsequently 
administered.  The  cavity  of  the  uterus  should  be  firmly 
plugged  with  iodoform  gauze.  To  reduce  as  far  as 
possible  the  loss  of  blood  incisions  through  the  fundus 
of  the  uterus  (and  they  should  be  transverse  according  to 
Fritsch)  are  recommended,  and  in  the  anterior  uterine 
wall,  so  that  in  case  suppuration  occurs  in  the  wall  of 
the  uterus,  it  may  be  localized  by  the  overlying 
omentum,  or   by  adhesions  with  the  adjacent  peritoneum 

397 


THE   PREVEXTIOX   OF  DISEASE 

and  abdominal  wall.  Haemorrliage  may  further  be 
ciiecked  by  applying  an  elastic  ligature  around  tlie 
lower  uterine  segment,  or  better  still  by  tbe  temporarj^ 
compression  of  tbe  uterine  and  ovarian  vessels  by  an 
assistant.  It  has  been  suggested  that  a  preliminary 
puncture  and  palpation  should  be  made  so  that  the 
subsequent  incision  may  not  involve  the  placental  site. 
On  the  other  hand,  the  quick  performance  of  the  operation 
seems  more  rational. 

It  is  most  important,  as  a  preventive,  that  eight  to  ten 
silk  or  catgut  sutures  should  be  passed  very  exactly 
through  the  entire  uterine  wall  but  not  including  the 
endometrium.  It  is  also  useful  afterwards  to  suture  the 
uterine  peritoneum  by  itself  in  a  way  similar  to  that 
in  Lembert's  suture  of  the  intestine.  Diaphoresis  should 
be  promoted  after  the  operation :  it  serves  not  only  to 
eliminate  toxines  but  also  to  control  the  after  pains.  For 
this  purpose,  and  at  the  same  time  to  prevent  vomiting, 
several  enemata  of  saline  solution  should  be  administered. 
An  ice  bag  should  be  placed  upon  the  abdomen  and  later 
a  wet  compress. 

The  above  holds  good,  mutatis  mutandis^  for  Porro's 
supravaginal  amputation  of  the  uterus.  The  pedicle  should 
be  treated  extraperitoneally  at  the  lower  angle  of  the 
abdominal  incision ;  or  should  be  covered  with  iodoform 
gauze,  and  so  cut  off  as  it  were  from  the  abdominal 
cavity :  this  method  is  preferred  by  the  author.  This  gauze 
is  brought  down  into  the  vagina.  Gauze  may  be  applied 
in  this  way  too  in  complete  rupture  of  the  uterus.  In 
osteomalachia  this  operation  serves  at  the  same  time  to 
prevent  subsequent  pregnancies. 

Preventive  treatment  in  symphysiotomy  consists  above 
all  in  avoiding  the  operation  in  private  practice  except 
in  very  rare  cases,  and  it  should  never  be  performed  in 
primiparae,  in  patients  who  are  already  infected,  or  in 
cases  where  the  foetal  membranes  have  ruptured  pre- 
maturely. The  foetal  bag  of  membranes  should  be  kept 
intact  or  be  replaced  by  the  action  of  a  hydrostatic  dilator. 
To  prevent  further  separation  or  straining  of  joints,  the 

398 


PROPHYLAXIS   IN  MIDWIFERY 

sides  of  the  pelvis  should  be  firmly  held  together  by 
pressure  on  the  trochanters,  and  the  child  should  be 
extracted  with  the  patient  in  Walcher's  "  hanging 
position."  The  pelvis  should  afterwards  be  held  together 
by  silver  wire  sutures  and  a  firm  pelvic  belt. 

Intra-uterine  plugging  with  iodoform  gauze  should  not 
be  lightly  nor  often  undertaken,  as  it  is  very  liable  to  lead 
to  infection.  For  uncontrollable  post-partum  haemorrhage 
due  to  inertia,  bimanual  massage  of  the  uterus  while  held 
anteflexed  should  first  be  used,  and  the  vaginal  portion  of  the 
cervix  may  then  be  drawn  down.  If  nevertheless  the  uterus 
fails  to  contract,  plugging  may  then  be  resorted  to — gauze 
soaked  in  cresol  or  lysol  solution,  or  a  ten  to  twenty  per 
cent,  solution  of  aluminium  acetate  is  best ;  the  latter  has 
the  property  of  stimulating  contraction  and  acts  as  a 
haemostatic.  We  must  also  be  cautious  in  the  use  of 
intra-uterine  irrigation,  for  sudden  abrupt  elevations 
of  temperature,  collapse,  and  rigors  with  or  without 
perimetritis  or  parametritis  may  often  be  observed  after 
intra-uterine  douching.  Two  or  three  irrigations  are 
the  maximum — corrosive  sublimate  should  not  be  used — 
the  fluid  should  be  injected  under  very  slight  pressure, 
with  a  double  tube  so  that  the  return  current  may  flow 
easily.  The  canula  should  be  inserted  very  carefully 
through  a  speculum  so  that  no  fresh  lacerations  may  be 
produced.  Air-bubbles  must  not  be  carried  in  with  the 
fluid  injected. 

The  application  of  steam  to  the  interior  of  the  uterus  may 
be  used  in  septic  abortions,  but  not  after  labour,  and  the  fol- 
lowing precautions  are  recommended :  one  application  only 
should  be  made  lasting  fifteen  to  thirty  seconds,  the  tempera- 
ture in  the  steam-vessel  being  105°  to  110°  C,  so  that  the 
entire  endometrium  may  not  be  affected.  The  tube  which 
is  passed  into  the  uterus  must  be  prevented  from  coming  into 
contact  with  the  cervical  wall  by  some  bad  conductor  of 
heat,  such  as  gauze,  to  prevent  burning  and  atresia  and 
subsequent  haematometra.  Before  introducing  the  instru- 
ment, the  length  of  the  uterine  cavity  should  have  been 
accurately  measured  to  prevent  perforation  of  the  uterine 

399 


THE   PREVENTION  OF  DISEASE 

wall.  The  catheter  should  be  moved  about  and  -withdrawn 
a  little  so  that  the  strong  contraction  which  is  excited  may 
not  bring  the  uterus  too  close  to  the  instrument  or  allow 
of  excessive  action  at  one  spot.  The  retained  products  of 
gestation  should  previously  have  been  removed. 

III.     Preventive  Treatment  in  the  Puerperium 

1.  PEEVENTIVE  TEEATMENT  OF  PUEBPEEAL  FETEE 

Preventive  treatment  consists  essentially  in  avoiding 
unnecessary  examinations  and  interference,  but  when  these 
become  necessary  the  strictest  antisepsis  should  be  observed 
in  one's  self  and  instruments,  in  the  patient  during  labour 
and  during  the  puerperium,  and  in  her  home  and  surround- 
ings. Rubber  gloves  are  recommended  for  very  busy 
practitioners.  Above  all  there  should  be  no  contact  with 
septic  things  or  septic  people.  Beds  are  not  seldom  the 
means  for  the  conveyance  of  infection.  Ulceration  after 
lacerations  and  incisions  is  avoided  by  the  methods  de- 
scribed above.  If  a  purulent  discharge  or  gonorrhoea 
was  present  before  labour,  weak  antiseptic  douches  under 
low  pressure  should  be  commenced  at  once  ;  a  one  per  cent, 
solution  of  lysol  or  metakresol  may  be  used,  but  no  corrosive 
sublimate. 

In  puerperal  endometritis  we  must  distinguish  between 
microbic  infection  which  is  virulent  and  that  which  is 
relatively  harmless.  This  is  determined  by  the  condition 
of  the  pulse,  not  by  the  temperature :  the  greater  its 
tension,  the  smaller  and  the  more  frequent  the  pulse  is, 
the  more  serious  is  the  infection  and  the  more  cautiously 
must  intra-uterine  interference  be  employed,  so  that  new 
channels  of  entry  into  the  body  may  not  be  provided  along 
the  lymph  and  blood  paths.  Intra-uterine  interference  is 
indicated  only  when  necrosed  pieces  of  the  placenta  or 
membranes  have  to  be  removed,  and  the  simplest  method 
is  the  best.  Curetting  should  not  be  attempted  during  the 
puerperium  after  full  term  delivery,  even  when  decomposed 
products  are  present.  The  latter  should  be  washed  out, 
or  removed  by  the  finger  when  this  can  be  done  without 

400 


PROPHYLAXIS  IN  MIDWIFERY 

producing  lacerations  while  dilating  the  cervix,  or  lastly 
may  be  cauterized  with  concentrated  carbolic  acid  or 
formalin  to  prevent  extension  of  the  infection.  It  is 
important  at  the  very  commencement  of  the  endometritis 
to  take  measures  to  limit  the  growth  of  microbes.  This  is 
best  done  by  good  drainage,  thus  carrying  off  the  lochial  dis- 
charge and  necrosed  portions  of  tissues,  and  for  this  purpose 
the  vagina  should  be  irrigated  several  times  a  day  with  a 
weak  antiseptic,  and  the  uterus  should  be  stimulated  to  con- 
tract more  strongly  by  placing  an  ice  bag  on  the  abdomen, 
or  by  wet  compresses,  and  by  the  regular  administration 
of  ergot.  The  uterine  contractions  will  expel  the  uterine 
contents,  and  will  at  the  same  time  restore  the  normal 
position  and  anteflexion  of  the  uterus.  Pieces  of  membrane 
and  retained  products  which  have  come  down  into  the 
cervix  may  be  removed  by  the  .  finger  or  by  polypus 
forceps  ;  the  vagina  should  be  douched  both  before  and  after. 
The  normal  position  and  slight  anteflexion  of  the  uterus 
allow  the  lochial  discharge  to  escape  freely,  while  a  lax 
walled  uterus  with  sacculi,  or  a  uterus  which  is  abnormally 
anteflexed,  leads  to  retention  of  lochial  discharge,  and  to 
absorption  of  septic  products  giving  rise  to  pyrexia.  These 
conditions  may  be  prevented — the  latter  by  warm  applica- 
tions, or  if  there  are  violent  colicky  after-pains  by  hot 
fomentations,  and  even  hot  vaginal  douches  and  enemata, 
the  former  by  an  ice  bag  and  by  narcotics  per  rectum. 
Ergot  prevents  the  occurrence  of  both  these  conditions. 

Preventive  treatment  for  the  other  serious  forms  of 
puerperal  fever  consists  in  the  early  treatment  of  the 
morbid  conditions  already  named,  the  ulcerations  and 
endometritis  and  puerperal  vaginitis.  These  serious  forms 
of  puerperal  sepsis  are  metritis,  parametritis  and  perimetritis, 
salpingitis  and  acute  oophoritis,  lymphangitis  and  phlebitis 
of  the  uterus,  and  lastly  general  peritonitis,  septicaemia 
and  sapraemia. 

The  further  extension  of  the  infection  is  checked  by  the 
frequent  use  of  ice,  and  when  there  is  peritonitis  by  opium 
in  small  doses.  The  virulence  of  the  microbes  is  lessened 
by  the  administration  of  mercury ;  the  power  of  resistance 

401  DD 


THE  PREVENTION  OE  DISEASE 

of  the  body  is  raised  not  only  by  stimulants  but  also  by 
removing  the  poison  from  the  body  and  eliminating  the 
toxines  by  diaphoresis,  frequent  evacuation  of  the  bowels, 
and  above  all  by  copious  injections  of  normal  saline 
solution,  that  is  '6  per  cent,,  in  the  form  of  enemata  or 
subcutaneously. 

There  is  a  wider  field  of  treatment  for  the  prevention  of 
septic  thrombosis  of  the  uterine  sinuses  and  pyaemia,  and 
preventive  treatment  here  is  the  more  important  seeing 
that  we  are  almost  powerless  to  cope  with  the  disease  when 
once  it  has  appeared. 

We  should  prevent  the  formation  of  large  thrombi 
beginning  at  the  placental  site,  and  it  is  equally  im- 
portant to  prevent  post-partum  and  puerperal  uterine 
haemorrhage.  The  causes  of  this  haemorrhage  should  there- 
fore be  constantly  borne  in  mind,  namely — 1.  Defective 
uterine  contraction  after  delivery,  either  from  irregularity 
in  contraction  of  the  various  parts  of  the  uterus,  as 
in  marginal  attachment  of  the  placenta ;  in  this  case 
the  haemorrhage  is  not  very  serious  ;  or  from  paralysis 
of  the  placental  site  only,  and  this  is  accompanied  by 
exceedingly  dangerous  haemorrhage.  2.  The  retention  of 
products  of  conception  produces  haemorrhage  generally 
during  the  first  week  only,  but  their  decomposition  causes  the 
thrombi  in  the  vessels  to  breakdown  and  so  leads  to  secondary 
haemorrhage.  3.  SUght  recurring  haemorrhages  appear- 
ing after  the  first  week  are  caused  by  subinvolution  of  the 
uterus,  especially  of  the  placental  site.  4.  This  atony  is  often 
produced  by  endometritis,  which  also  causes  haemorrhage 
by  giving  rise  to  decomposition  of  thrombi  and  to  inflam- 
matory hyperaemia.  5.  Haemorrhages  are  caused  not  only 
by  congestion  following  relaxation  of  the  blood  vessels,  but 
also  by  venous  stasis,  which  gives  rise  also  to  thrombi. 
The  venous  stasis  may  be  the  result  of  anomalies  in  inner- 
vation, of  the  patient  getting  up  too  soon  when  there  is  a 
predisposition  to  subinvolution,  of  an  overfilled  bladder 
or  rectum,  of  excessive  straining  at  stool,  of  coughing  or 
of  work,  and  of  disturbances  of  the  circulation  produced  by 
flexion  and  displacement  of  a  sacciform  uterus. 

402 


PEOPHYLAXIS   IN  MIDWIFERY 

Emotioual  disturbances  and  sadden  attacks  of  fever  aid 
these  predisposing  factors  by  giving  rise  to  acute  hyper- 
aemia. 

Decomposition  of  thrombi  should,  as  already  stated,  be 
prevented  by  the  immediate  treatment  of  commencing 
puerperal  endometritis. 

If  decomposition  has  set  in,  the  breaking  down  of  the 
thrombi  and  the  formation  of  emboli  is  prevented  by 
securing  contraction  of  the  uterus,  by  removing  lochial 
discharges  by  means  of  antiseptic  irrigation,  and  by  abso- 
lute rest  in  bed.  The  patient  must  not  be  allowed  to  wash 
or  dress  herself,  or  to  sit  up  for  any  purpose.  Constipation 
and  coughing  must  be  prevented,  and  errors  in  diet  must  be 
avoided  ;  a  liquid  nourishing  diet  is  best.  If  nevertheless 
emboli  form,  symptomatic  treatment  is  required.  All  that 
can  be  done  in  such  cases  to  prevent  the  action  of  these 
injurious  factors  is  comprised  under  the  rules  given  for 
para-  and  perimetritis. 

2.  PREVENTIVE  TREATMENT  FOR  RELAXED  CONDITIONS 
OF  THE  PELVIC  AND  ABDOMINAL  ORGANS 

The   puerperal   period    afifords   a    good    opportunity   for 
restoring   the   lost  tone  of   the  striated   and   non-striated 
muscular  fibres  and  of  all  the  elastic  and  contractile  ele- 
ments of  the  abdominal  walls,  the  intestines  and  generative 
organs  and  the  ligaments  of  the  pelvis.    That  the  puerperal 
period  alone  is  the  cause  of  this  loss  of  tone  is  not  correct. 
The  beginnings  of  that  relaxed  state  are  often  evident  even 
soon  after  puberty  in  neurasthenic  girls  who  are  predisposed 
to  it  and  who  are  generally  also  chlorotic.    Every  subsequent 
severe  strain  or  abdominal  inflammation  serves  to  aggravate 
the  condition ;  pregnancy  is  one  such  strain,  and  the  liga- 
ments should  be  relieved  by  the  use  of  a  pessary  up  to  the 
fourth  month,  and  the  abdominal  wall  should  be  S2:)ecially 
treated  after  the  fifth  month.      Even  more  important  is  the 
general  treatment  to  raise  the  tone    and   strength  of  the 
body ;  this  has  been  already  given  in  detail  in  the  section 
on  Gynaecology.     This  must  be  pursued  energetically  and 
persistently  in  the  puerperium.     Unfortunately  the  greater 

403 


THE  PREVENTION  OF  DISEASE 

number  of  nurses  have  no  knowledge  of  or  wish,  to 
understand  this  treatment ;  at  the  most  they  merely  heap 
a  mass  of  linen  upon  the  abdomen  of  the  patient,  which 
in  some  ways  is  useful  but  in  others  injurious.  Many 
patients  too  regard  all  efforts  in  this  direction  as  an  unne- 
cessary trouble,  so  that  even  when  the  physician  is  called 
in  for  advice  in  the  puerperal  period  he  preaches  to  deaf 
ears.  He  must  suggest  practical  measures  and  he  should 
see  that  these  are  carried  out ;  and  he  will  need  to  be  very 
alert  because  the  nurse  will  often  disregard  his  instruc- 
tions. It  is  best  to  gain  the  ear  of  the  patients  through 
their  vanity,  by  jDointing  to  the  terrible  size  of  the  abdomen 
of  friends  whom  they  know.  Soon  after  delivery  a  belt 
should  be  applied  to  the  abdomen :  it  should  be  convex, 
reach  to  above  the  umbilicus  and  have  five  or  six  buckles 
and  straps  reaching  down  to  the  groin.  Instead  of  this, 
long  wide  closely-woven  cloths  or  towels  may  be  used,  and 
these  may  further  be  weighted.  After  the  fifth  day  the 
abdomen  should  be  massaged  several  times  a  day  if  there 
are  no  signs  of  inflammation.  A  regular  action  of  the 
bowels  should  be  secured.  Flatulence  should  be  treated  by 
oil  of  peppermint  or  by  enema.  The  bladder  should  also  be 
regularly  emptied.  And,  if  there  is  no  contra-indication, 
the  patient  should  twice  a  day  practise  using  the  abdominal 
muscles  by  carefully  raising  herself  in  bed.  For  success  it 
is  most  important  too  to  establish  an  efficient  lactation,  and 
abdominal  massage  acts  reflexly  and  favourably  in  this 
respect. 

For  subinvolution  of  the  uterus  ergot  should  be  regularly 
administered.  For  descent  of  the  uterus  and  prolapse  of 
the  vagina  a  pessary  should  be  inserted,  and  later  tampons 
of  glycerine  of  tannin  employed. 

3.  PEEVENTIVE  TEEATMENT  FOR  DISORDEES  IN  THE 
PUERPERIUM  ARISING  FROM  TUMOURS  OF  THE  GEN- 
ERATIVE ORGANS 

Fibroids  diminish  in  size  in  the  puerj)erium,  but  very 
readily  undergo  nutritive  and  necrotic  changes.  Ovarian 
cysts  increase  in  size  and  often  undergo  necrotic  changes 

404 


PROPHYLAXIS  IN  MIDWIFERY 

through  torsion  of  the  pedicle  or  contusion.  Such  tumours 
and  sometimes  the  entire  uterus  must  be  removed  to  prevent 
a  fatal  issue.  Polypi  should  be  at  once  removed  for  the 
same  reason.  The  preventive  treatment  for  disturbances  in 
the  puerperium,  arising  from  general  disease  and  disease  of 
other  organs  than  the  genitals,  has  already  been  described. 
The  chief  diseases  are  erysipelas,  pneumonia,  influenza, 
phthisis,  uncompensated  cardiac  lesions  which  readily  lead  to 
oedema  of  the  lungs,  neuritis,  mental  disorders,  renal  disease 
and  diseases  of  metabolism.  With  regard  to  multiple  neuritis 
it  must  be  mentioned  that  this  is  generally  the  result  of 
septic  infection,  sometimes  through  the  use  of  too  strong 
disinfectants,  sometimes  through  bruising  of  the  tissues 
during  labour. 

4.     PRE^^ENTIVE  TREATMENT  OF  MASTITIS 

The  hygienic  recommendations  given  under  the  heading 
of  "  General  Preventive  Measures,"  should  be  carried  out. 
I  consider  it  harmful  to  harden  the  nipples  by  rubbing  with 
brandy ;  it  is  better  to  wash  them  daily  with  cold  water,  and 
to  brace  and  improve  the  general  constitution.  On  the  other 
hand,  extension  of  the  inflammatory  process  must  be  pre- 
vented by  looking  for  the  fissure  of  the  nipple  and  treating 
it  with  lead  lotion  compresses,  or  compresses  soaked  in  a 
solution  of  aluminium  acetate,  which  should  be  renewed 
every  two  to  ten  minutes,  or  lastly  by  an  ice  bag  with  a 
thin  piece  of  flannel  underneath  it.  To  prevent  fissures, 
glass  shields  with  elastic  nipples  may  be  employed. 


405 


The  Prevention  of  the   Diseases 
of  Children 

BY 

DR.   RUDOLF   FISCHL 

LECTURER  ON  THE  DISEASES  OP  CHILDREN  IN  THE 
GERMAN  UNIVERSITY  OF  PRAGUE 


407 


The  Prevention  of  the  Diseases 
of  Children 

The  proper  care  and  regulation  of  life,  the  avoidance  of  all 
injurious  factors,  tlie  isolation  of  patients  suffering  from 
infectious  disease,  the  strengthening  of  the  body  by  suitable 
diet,  by  living  in  the  fresh  air  of  the  country,  of  the  moun- 
tains, or  at  the  seaside,  hardening  the  system  by  attention 
to  clothing,  and  by  care  of  the  skin — these  means  to  prevent 
the  development  or  the  spread  of  disease,  have  been  em- 
ployed nowhere  so  long  and  so  thoroughly  as  in  childhood. 
These  were  the  guiding  principles  of  the  physicians  of  old, 
though  their  methods  had  not  been  confirmed  by  the  results 
of  bacteriological  research.  The  relatively  high  stage 
reached  in  the  treatment  of  the  diseases  of  children,  the 
branch  of  practical  medicine  now  to  be  considered,  makes  it 
necessary  that  it  shall  be  dealt  with  in  this  work  in  some- 
what greater  detail  than  the  other  subjects.  I  would,  there- 
fore, in  these  introductory  remarks,  ask  the  indulgence  of 
the  reader  for  the  greater  length  of  this  part,  which  is 
necessitated  by  the  circumstances  of  the  case. 

It  will  not  be  possible  to  treat  the  whole  subject  exhaus- 
tively :  firstly,  because  the  constant  advance  of  scientific 
knowledge  compels  us  to  take  an  expectant  attitude 
towards  certain  questions  connected  with  preventive  treat- 
ment ;  secondly,  because  this  work  is  addressed  mainly  to  the 
medical  practitioner,  and  he  does  ask  not  for  a  compila- 
tion of  the  results  of  literary  study,  but  for  information 
derived  from  and  based  upon  the  author's  own  clinical 
experience,  which  may  serve  as  a  guide  in  his  own  practice. 
It  is  obvious  that  local  circumstances  and  other  external 

409 


THE  PREVENTION  OF   DISEASE 

conditions  must  impose  certain  limitations  upon  the  indi- 
vidual experience  of  any  one  physician,  but  it  seemed  to  me 
best  to  follow  this  personal  method  and  sacrifice  in  some 
degree  the  completeness,  and  I  proceed,  therefore,  to  describe 
almost  exclusively  that  which  a  clinical  practice  extending 
over  15  years  has  shown  to  be  most  valuable  and  beneficial. 
Before  describing  the  preventive  treatment  of  the  different 
groups  of  diseases,  I  will  make  a  few  general  remarks.  The 
several  periods  of  child-life  require  each  a  different  hygiene 
which  comprises  mostly  those  prophylactic  measures  which 
are  best  adapted  to  prevent  the  development  of  disease.  In 
the  new-born  infant — using  this  term  to  denote  the  child 
during  the  period  between  birth  and  the  complete  healing 
of  the  umbilical  wound  which  is  the  last  sign  of  the  pre- 
vious physical  connection  with  the  mother — the  chief  aim 
must  be  perfect  asepsis  to  prevent  the  introduction  of  germs 
into  its  body,  for  which  there  are  so  many  opportunities, 
and  to  prevent  germs  which  may  have  reached  the  skin  or 
mucous  membranes  from  becoming  active  and  causing 
infection.  In  the  second  period — that  period  during  which 
the  child  is  or  should  be  breast-fed — the  chief  dangers 
which  threaten  its  life  and  health  are  digestive  troubles, 
and  these  are  best  warded  off  by  correct  feeding.  Other 
dangers,  such  as  those  arising  from  colds  and  from  infec- 
tion, are  only  of  secondary  importance.  Early  childhood — 
the  period  up  to  the  commencement  of  the  second  denti- 
tion— is  essentially  the  chief  time  for  the  various  acute 
infectious  diseases.  The  rapid  growth  of  certain  organs 
enables  disease  germs  to  effect  an  easy  lodgment,  the  in- 
creasing independence  of  the  child  exposes  it  in  a  greater 
degree  to  the  ill  effects  of  bad  weather,  and  games  and  other 
occupations  afford  many  opportunities  for  acquiring  disease. 
Here,  the  aim  of  preventive  treatment  must  be  to  fortify 
the  system  against  disease,  to  ensure  the  supervision  of 
patients  suffering  from  infectious  disease,  and  to  promote 
cleanhness  in  children's  games  and  at  meals.  Late  child- 
hood— the  period  up  to  puberty — is  still  exposed,  in  part, 
to  the  dangers  which  threaten  early  childhood  and  to  the 
additional  risk  of  ill-effects  which  may  result  from  school 

410 


THE  PREVENTION  OE  THE  DISEASES  OF  CHILDREN 

education  and  mental  work,  and  thus  preventive  treatment 
merges  into  the  hygiene  of  education. 

The  whole  subject  may,  therefore,  be  roughly  divided 
into  several  groups,  according  to  the  age  of  the  children, 
each  group  characterized  by  its  own  peculiar  dangers  to 
health.  The  possibilities  of  preventive  treatment  are  not, 
however,  confined  to  this.  Often,  especially  in  the  chronic 
infections  of  syphilis  and  tuberculosis,  the  physician  is 
obliged  to  enquire  into  the  social  life  of  the  members  of  the 
family  and  give  advice  before  conception  has  occurred.  This 
branch  of  prophylactic  treatment  is,  unfortunately,  too 
little  practised,  in  spite  of  its  immense  importance  for 
entire  generations,  and  it  is  partly  also  beyond  the  influ- 
ence of  the  physician. 

A  further  scope  for  preventive  treatment  lies  in  preventing 
complications  from  arising  in  disease  in  children.  The  task 
is  not  only  to  limit  the  actual  number  of  infectious  cases 
by  isolation  and  disinfection,  but  also  to  check  the  infective 
process  in  the  patient  himself,  and  to  protect  him  from 
germs  which  give  rise  to  complications  often  far  more  dan- 
gerous than  the  primary  disease.  In  this  way  preventive 
treatment  may  act  most  effectually  and  beneficially  against 
the  acute  and  chronic  infective  processes  of  child-life. 

In  these  introductory  remarks,  I  must  not  omit  to  men- 
tion one  other  matter,  which  I  will  term  the  prophylaxis  of 
treatment ;  by  this  I  mean  caution  in  the  use  of  certain 
methods  of  treatment  to  which  children  are  very  suscep- 
tible because  of  idiosyncrasies  peculiar  to  childhood.  Many 
mistakes  have  been  and  are  still  made  in  this — mistakes 
which  are  doubly  serious  because  they  also  injure  the 
physician  and  lower  the  good  reputation  of  our  profession. 
The  subject  will  be  treated  according  to  the  plan  sketched 
out  above,  beginning  with 

PREVENTIVE  TREATMENT  IN  THE  NEW-BORN  INFANT 

Apart  from  those  cases  where  the  infective  process  reaches 
the  foetus  by  way  of  the  placenta  and  causes  premature 
expulsion  of  the  foetus,  death  of  the  foetus,  or  infection  of 
the  child  in  utero,  and  which  do  not  come  within  the  scope 

411 


THE   PREVENTION  OF  DISEASE 

of  OTir  subject,  there  are  otliers  -wliere  tlie  germs  of  disease 
enter  the  body  of  the  nnborn  child  through  microbic  con- 
tamination of  the  liquor  amnii  when  the  foetal  membranes 
have  become  prematurely  ruptured.  Such  cases  are  very 
rare,  and  we  are  almost  powerless  to  do  anything  against 
the  disease — generally  a  septic  pneumonia — caused  by  the 
contaminated  liquor  amnii.  Infection  may  also  take  place 
during  the  passage  of  the  child  through  the  genital  canal, 
when  some  infectious  secretion  from  the  mother's  vagina 
penetrates  into  some  cavity  or  recess  in  the  child — the  con- 
junctiva, the  mouth,  the  vagina,  or  the  rectum — or  it  may 
enter  and  become  lodged  in  some  wound  of  the  child's  skin, 
produced  during  parturition.  The  chief  of  these  infections 
is  purulent  conjunctivitis  of  new-born  children,  which  is 
partly  gonorrhoeal  and  partly  purulent.  The  great  fre- 
quency formerly  of  this  eye  affection,  and  its  severity  as 
evidenced  by  the  fact  that  nearly  one-third  of  all  cases  of 
blindness  can  be  referred  to  this  cause,  long  ago  attracted 
the  attention  of  physicians  and  especially  of  obstetricians. 
Preventive  measures  were  recommended,  and  the  good  effect 
of  these  is  beyond  doubt.  Crede's  method  is  the  best ;  it 
consists  in  washing  out  the  vagina  of  the  mother  with  a 
solution  of  corrosive  sublimate,  several  times,  before  the  com- 
mencement of  the  second  stage  of  labour,  and  in  dropping 
into  each  eye  of  the  child  a  drop  of  some  astringent  liquid 
directly  after  birth,  before  the  umbilical  cord  is  severed. 
A  2  per  cent,  solution  of  silver  nitrate  may  be  used  for 
this  purpose ;  recently  a  10  to  20  per  cent,  solution  of 
protargol  has  been  employed,  or  lemon-juice  may  be  used, 
or  iodoform  may  be  dusted  in.  It  is  important,  as  already 
stated,  that  this  treatment  should  be  carried  out  directly 
after  the  birth  of  the  child,  because  the  experience  furnished 
by  lying-in  institutions  proves  that  this  very  early  treat- 
ment influences  the  frequency  of  conjunctivitis  much  more 
than  the  same  treatment  later.  To  use  some  substance 
(protargol  or  iodoform)  which  is  less  irritating  to  the 
palpebral  conjunctiva  than  the  silver  salt  first  recom- 
mended, is  desirable  too  as  a  preventive  measure  because  it 
prevents   the   possibility  of  an   artificially   produced  con^ 

412 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

junctivitis  aud  subsequent  secondary  infection  of  tlie  in- 
flamed conjunctiva.  When  gonorrlioeal  conjunctivitis  is 
present,  preventive  measures  must  be  taken,  and  foremost 
among  these  must  be  the  prevention  of  extension  of  the 
inflammatory  process  to  the  cornea,  and  its  subsequent 
deleterious  effects  upon  vision.  This  can  only  be  accom- 
plished by  the  immediate  removal  from  the  palpebral  con- 
junctiva of  the  secretions.  For  this  purpose,  the  eyes  should 
be  washed  out  with  sterilized  water  or  with  a  weak  anti- 
septic. Potassium  permanganate  is  especially  to  be  recom- 
mended for  its  slightly  astringent  properties.  I  -pveter  to 
postpone  the  use  of  silver  nitrate  or  protargol  to  a  later 
stage,  when  the  swelling  and  secretion  of  the  conjunctiva  are 
subsiding  under  the  influence  of  the  mechanical  removal  of 
the  purulent  discharge  and  the  application  of  cold  compresses. 
Experience  has  taught  me  that  the  healing  process  is  accele- 
rated thereby.  I  do  not  employ  ice  but  only  moderate  cold, 
and  thus  avoid  the  risk  of  inducing  superficial  necrosis  of 
the  conjunctiva. 

A  further  important  factor  is  the  protection  of  the  healthy 
eye  when  one  eye  only  is  affected ;  it  should  not  be  covered 
up,  because  commencing  inflammation  which  could  be 
immediately  treated  may  in  this  way  be  overlooked.  Grreat 
care  is  required  in  washing  out  the  inflamed  eye ;  the 
stream  should  be  directed  from  the  inner  canthus  towards 
the  outer  to  prevent  any  secretion  from  flowing  towards 
the  healthy  eye ;  the  sound  eyeball  should  not  be  touched 
when  treating  the  inflamed  one.  The  hands  should  be 
most  carefully  cleansed  with  warm  water,  soap  and  brush, 
alcohol  and  ether  ;  pieces  of  wool  and  gauze  which  have  been 
used  should  be  destroyed  at  once  and  this  is  best  done  by 
burning. 

Care  is  required  to  prevent  the  purulent  discharge  from 
flowing  into  the  mouth,  or  from  getting  into  any  abrasion 
of  the  skin,  or  from  reaching  the  genitals,  especially  in  girls. 
One  nurse  should  be  appointed  to  look  after  the  eye,  and  her 
whole  time  must  be  given  up  to  this.  ♦  All  linen  used  for 
the  child  should  be  washed  separately ;  the  child  must  be 
isolated  and  kept  away  from  its  brothers  and  sisters  until 

413 


THE   PREVENTION  OF  DISEASE 

the  normal  appearance  of  tlie  conjunctiva  and  microscopical 
examination  of  tlie  secretion  show  that  there  is  no  longer 
any  infection.  The  sick  room  should  afterwards  be 
thoroughly  disinfected  (see  below)  as  well  as  all  utensils, 
especially  the  bath.  The  irrigator  used  for  washing  out 
the  eye,  or  at  least  the  nozzle  of  it,  should  be  destroyed. 
In  institutions,  where  several  such  cases  may  occur  at  a 
time,  the  affected  children  should  be  isolated  in  light,  well- 
ventilated  rooms  which  have  been  previously  disinfected, 
and  their  attendants  should  have  been  trained  in  the  treat- 
ment of  the  eyes,  and  should  not  be  employed  for  any  other 
work  at  the  same  time. 

During  the  passage  of  the  child  through  the  genital  canal, 
infectious  germs  may  reach  the  cavity  of  the  mouth  in  the 
same  way  as  they  reach  the  eye,  and  may  set  up  inflamma- 
tion.    There  are  no  special  prophylactic  measures  against 
this,  but  we  can  do  something  by  avoiding  any  injury  to 
the  buccal  mucous  membrane.     This  subject  will  be  dealt 
with  later,  when  speaking  of  infections  of  the  buccal  cavity. 
It  is  possible  also  for  the  germs  found  in  the  maternal 
vagina  to  become  lodged  in  wounds  of  the  skin,  which  have 
been  caused  during  parturition,  for  instance,  by  forceps. 
After  treating  the  eyes  by  Crede's  method  and  severing  the 
umbilical  cord,  the  child  should  be  thoroughly  washed  and 
any  lesion  of  the  skin  should  be  dressed  with  an  antiseptic. 
By  these  means  dangers  from  this  source  are  averted.     It 
is  obvious  that  in  institutions  such  children  should  be  kept 
away   from  rooms  in   which  there  are  patients  with  any 
purulent  discharge. 

And  lastly,  mention  must  be  made  of  infection  of  the 
genitals  and  of  other  infections  occurring  during  birth. 
The  former  occur  principally  in  girls  and  cause  vulvo- 
vaginitis, and  in  cases  which  are  suspicious  Epstein  recom- 
mends that  the  vagina  should  be  washed  out  with  a  weak 
antiseptic  lotion,  such  as  one  of  j)otassium  permanganate 
and  a  2  per  cent,  solution  of  silver  nitrate  injected  as  a 
precautionary  measure.  Infections  at  the  anal  orifice 
during  parturition  can  only  be  influenced  by  very  careful 
cleansing  of  this  region  in  the  first  bath. 

414 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

The  cliild,  after  its  expulsion  from  the  uterus,  is  in  a 
medium  richly  supplied  with  microbes,  some  of  them  patho- 
genic, and  the  fact  that  parts  of  its  body,  such  as  the  mouth 
and  the  alimentary  canal,  "which  contained  no  microbes  at 
birth,  are  found  a  few  hours  later  to  possess  a  rich  flora  of 
microbes,  shows  clearly  that  manj^  oj)portunities  are 
afforded  for  bacteria  to  attack  the  delicate  organism  of  the 
child,  and  that  precautionary  measures  are  required  to  limit 
these  dangers  so  far  as  is  possible.  "We  shall  briefly  con- 
sider these  various  regions  separately,  commencing  with 
that  which  is  of  the  greatest  importance  in  the  new-born 
infant — the  umbiKcus. 

During  the  division  and  ligature  of  the  cord  it  is  possible 
for  pathogenic  germs  to  reach  the  child's  body  by  soiled 
hands,  by  scissors  and  ligatures  which  have  not  been 
thoroughly  cleansed.  The  strictest  cleanliness  is  therefore 
required ;  the  interval  which  elapses  between  the  birth  of 
the  child  and  cessation  of  pulsation  in  the  umbilical  cord 
should  be  utilized  for  a  thorough  disinfection  of  the  hands. 
A  double  ligature,  which  has  been  previously  sterilized  by 
boiling,  should  be  passed  round  the  cord  and  tied,  and  the 
cord  be  divided  with  sterilized  scissors.  Elastic  ligatures 
should  not  be  used,  for  it  is  very  difficult  to  sterilize  them, 
and  they  possess  other  disadvantages.  Different  views  are 
held  about  the  measures  to  be  adopted  for  the  desiccation  of 
the  cord,  and  until  the  question  has  been  finally  deter- 
mined it  is  best  to  carry  out  an  accepted  method  and  to 
guard  against  its  dangers ;  no  harm  can  result  from  taking 
precautions.  The  child  should  be  put  into  a  bath,  of  porce- 
lain or  metal  by  preference  and  having  no  corners,  filled 
with  water  which  has  been  boiled  and  allowed  to  cool  down 
sufficiently.  G-auze  or  linen  which  has  been  previously 
boiled  should  be  used  to  wash  the  child,  and  not  the  ordinary 
unreliable  sponge.  The  same  kind  of  material  should  be 
used  for  drying  the  child,  and  the  navel  should  then  be 
bandaged.  To  prevent  infection,  it  is  necessary  to  ensure 
the  mummification  of  the  cord,  which  will  then  not  afford  a 
suitable  soil  for  microbes,  and  further  to  hasten  the  falling 
off  of  the  cord  and  to  let  cicatrization  go  on  unhindered  so 

415 


THE  PREVENTION   OF  DISEASE 

that  germs  may  not  enter  the  umbilical  region.  These 
requirements  are  best  fulfilled  by  a  dry  bandage,  which  does 
not  drag  upon  the  cord  and  which  permits  access  of  air. 
For  this  I  employ  a  piece  of  cotton  wool  cut  in  the  form  of 
a  rectangle  with  a  hole  through  the  middle  for  the  umbilical 
cord,  and  fastened  by  a  short  binder  passing  round  the  body. 
Cotton  wool  intercepts  germs  which  are  in  the  air  much 
more  efficiently  than  gauze,  and  fulfils  all  other  require- 
ments. The  question  of  the  protective  bandage  appeared  to 
have  been  definitely  answered,  yet  it  has  recently  again 
come  to  the  front,  together  with  the  question  whether,  with 
the  object  of  preventing  possible  infection,  it  is  better  after 
the  first  bath  of  the  child  to  postpone  the  second  bath  till 
after  the  cord  has  fallen  off.  I  do  not  approve  of  this 
method  and  do  not  think  there  are  well-founded  reasons  for 
it;  it  has  not  been  shown  that  cicatrization  of  the 
umbilicus  has  been  delayed  by  the  daily  bath ;  the  danger 
of  the  entrance  of  germs  through  this  proceeding  is  reduced 
to  a  minimum  if  the  bath  is  carefully  cleansed  and  boiled 
water  is  used,  and  the  daily  bath  has  a  number  of  other 
hygienic  and  23ro23hylactic  advantages  which  far  outweigh 
the  disadvantages.  The  best  way  to  prevent  the  cord  from 
being  dragged  upon  is  to  have  it  as  short  as  convenient, 
and  to  handle  it  as  little  as  possible  each  time  the  bandage 
is  changed.  The  use  of  dusting  powder  is  unnecessary  and 
has  its  inconveniences ;  the  substances  generally  used  are 
not  free  from  germs,  and  antiseptic  powders  are  sometimes 
not  well  borne,  for  example,  iodoform  often  causes  eczema, 
and  sometimes  they  delay  mummification  ;  they  are,  there- 
fore, best  omitted.  After  the  cord  has  fallen  away,  a  piece 
of  cotton  wool  should  be  kej)t  over  the  navel  to  protect  it 
from  dust,  until  complete  healing  prevents  the  possibility  of 
germs  entering  by  this  channel.  The  bandage  must  be 
renewed  whenever  it  becomes  soiled  by  faeces  or  urine,  and  in 
every  case  it  should  be  changed  at  least  once  a  day  directly 
after  the  bath  ;  the  strictest  cleanliness  here,  too,  is  needed, 
and  hands  which  have  touched  the  soiled  bandage  should  be 
thoroughly  cleansed  before  they  are  used  to  put  on  the  fresh 
bandage.     These  details  cannot  be  too  often   emphasized, 

416 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

especially  as  tlie  directions  are  not  carried  out  by  the  doctor 
but  by  nurses,  and  need  to  be  strongly  impressed  upon  them 
by  demonstration  and  by  supervision  to  see  that  they  are 
understood  and  carried  out.  In  private  cases,  such  infection 
by  contact  plays  a  far  less  important  part,  though  even  here 
it  may  happen  that  a  nurse  who  is  entrusted  with  the  care 
of  several  mothers  and  children  may  dress  a  child  suffering 
from  erysipelas  of  the  umbilicus,  and  then  after  merely 
washing  her  hands  dress  a  healthy  navel.  If  it  is  unavoid- 
able that  she  should  attend  to  both  cases,  and  even  to  other 
cases,  then,  at  whatever  personal  inconvenience  to  herself, 
the  infectious  case  should  always  be  the  last  in  turn,  and 
the  hands  should  afterwards  be  thoroughly  cleaned  and 
nothing  more  undertaken  on  that  day.  Midwives  who 
attend  to  patients  who  are  ill  with  puerperal  fever  should 
not  undertake  any  other  cases,  and  this  is  even  more 
important  still  for  the  doctor  who,  with  his  knowledge  and 
conscientiousness,  should  set  an  example  to  those  under 
him. 

Before  passing  on  to  other  possible  ways  of  infection  of 
new-born  infants  and  the  measures  for  their  prevention, 
I  will  briefly  allude  to  a  few  general  rules.  The  child 
should  always  be  attended  to  first  and  the  mother  after- 
wards. In  this  way  only  is  it  possible  to  make  sure  that 
no  maternal  secretions  are  carried  to  the  child,  for  even 
the  normal  lochial  discharge  may  contain  germs  that  are 
infective  for  the  child.  I  have  already  mentioned  the  bath  ; 
with  regard  to  the  bath  water,  boiled  water  should  be  used 
till  the  umbilicus  is  perfectly  healed,  and  so  long  as  there 
are  any  skin  lesions  or  inflammatory  processes  with  loss 
of  substance.  I  have  spoken  also  of  the  washing  materials  ; 
no  sponges,  but  pieces  of  gauze  or  boiled  linen  should  be 
used.  I  would  only  add  that  water  in  a  separate  basin 
and  fresh  pieces  of  linen  should  be  used  for  washing  the 
face,  otherwise  germs  cannot  fail  to  be  carried  to  the  face 
which  have  got  into  the  water  from  the  skin  or  bowel. 
The  bath  should  be  thoroughly  cleansed  each  time  after 
use  and  then  carefully  covered  over  till  next  required. 
The  same  bath  must  never  be  used  for   several    children 

417  E  E 


THE  PREVENTION  OF  DISEASE 

after  merely  changing  the  water  and  rinsing  out  the  bath  ; 
when  it  is  necessary  to  use  it  for  several  children  it  must 
be  thoroughly  cleaned  out  for  each  child  and  the  bath 
must  be  of  metal  or  earthenware  to  make  sure  that  it 
can  be  thoroughly  cleaned.  Great  importance  should  be 
attached  to  this  matter  in  institutions,  as  very  serious 
consequences  have  occurred  through  infection  conveyed 
by  the  bath  water,  the  baths  or  the  sponges. 

The  mouth  should  be  cleared  directly  after  birth, 
and  sometimes  this  is  directly  indicated  as  in  asphyxia. 
It  should  be  done  by  the  doctor  and  every  care  taken 
to  avoid  injuring  the  mucous  membrane  and  so  opening 
a  door  for  the  numerous  microbes  which  are  present  in 
the  mouth.  "When  it  becomes  necessary  to  pass  a  catheter 
into  the  air  passage  great  care  must  be  taken  not  to  injure 
the  mucous  membrane  because  very  severe  infection  has 
been  observed  after  intubation.  The  subsequent  cleansing 
of  the  mouth  cavity  with  a  piece  of  linen  on  a  finger, 
which  the  nurse  generally  does  daily  after  she  has  bathed 
the  child,  I  look  upon  not  only  as  superfluous  but  also 
as  directly  injurious.  Superficial  lesions  of  the  epithelium 
can  scarcely  be  avoided  by  this  procedure  ;  the  so-called 
Bednar^s  aphthae^  which  may  be  the  starting  point  of  the 
severest  general  infection,  has  been  proved  by  Von  Epstein 
and  myself  to  have  been  caused  in  this  way.  Thrush  is 
also  apt  to  follow  these  manipulations  of  the  mouth  which 
have  artificially  produced  the  stomatitis  necessary  for  this 
condition,  and  the  germs  may  be  carried  in  by  the  finger 
nails.  In  short,  a  number  of  troubles  may  be  caused  by  the 
procedure  without  any  advantages  which  might  com- 
pensate for  them.  As  to  thrush,  catarrh  of  the  buccal 
cavity  and  dyspepsia  are  the  conditions  necessary  for  its 
development ;  if  the  buccal  catarrh  is  only  a  part  of  the 
general  digestive  trouble  then  washing  out  the  mouth 
will  not  prevent  thrush.  If  the  thrush  is  of  a  directly 
contagious  nature  interference  with  the  mouth  may  convey 
infection — in  short,  in  breast-fed  children  there  is  no  good 
reason  whatever  for  undertaking  it,  and  my  experience 
has  been  that  under  ordinary  normal  conditions,  nothing 

418 


THE  PREA^ENTION  OF  THE  DISEASES  OF  CHILDEEN 

but  good  has  resulted  from  its  omission.  The  case  is 
different  when  the  child  has  to  be  artificially  fed,  and 
there  is  frequent  regurgitation  of  milk,  and  large  flakes 
of  curdled  milk  lodge  in  the  buccal  pouches  and  afford 
a  suitable  nidus  when  the  temperature  is  favourable  for 
the  growth  of  the  microbes  which  are  already  in  the 
mouth  or  are  brought  there  by  the  milk  and  which  may 
set  up  irritation.  When  the  child  is  artificially  fed  I 
have  the  mouth  cleansed  each  time  the  child  is  fed.  This 
is  very  carefully  done  with  pledgets  of  cotton  wool  and 
never  with  a  camel  hair  brush  which  cannot  be  properly 
cleaned.  In  breast-fed  children  any  affection  of  the  mouth, 
if  it  does  not  already  exist,  may  be  prevented  by  washing 
the  nipples  of  the  mother  or  wet  nurse  with  a  2  to 
3  per  cent,  solution  of  boric  acid  both  before  and  directly 
after  the  child  is  put  to  the  breast.  If  some  affection 
is  already  present — and  there  are  cases  in  which  gonor- 
rhoeal  stomatitis  exists  when  the  child  is  born — the  chief 
care  must  be  to  prevent  the  inflammation  from  extending 
to  the  pharynx  and  larynx,  or  to  the  salivary  glands, 
or  especially  to  the  middle  ear.  This  is  done  by  early 
and  careful  treatment,  the  principles  of  which  cannot  be 
entered  into  here.  The  importance  of  the  mouth  as  a 
place  of  entry  for  infectious  germs  has  been  sufficiently 
dwelt  upon,  and  the  mucous  membrane  of  the  nose  must 
next  be  considered,  though  the  infective  process  begins 
here  much  less  frequently.  Nevertheless  attempts  are 
often  made  in  the  nursery  to  remove  inspissated  nasal 
secretion  with  a  twisted  corner  of  the  handkerchief  or 
with  hairpins  and  such  things  have  been  observed  some- 
times to  produce  abrasions  and  sometimes  to  convey  germs 
and  implant  them.  The  germs  most  commonly  so  conveyed 
are  the  pyogenic  streptococci  so  frequently  found  on  the 
scalp  and  in  the  nasal  cavities  of  adults.  Many  cases 
of  erysipelas,  starting  from  the  nasal  cavity,  and  many 
cases  of  rhinitis  are  produced  in  this  way.  To  prevent 
this  danger  all  such  methods  of  clearing  the  nostril  should 
be  forbidden  ;  the  inspissated  secretion  may  be  removed 
by  washing  out  the  nostril  with  lukewarm  sterilized  water 

419 


THE  PREVENTION  OF  DISEASE 

or  a  weak  antiseptic,  or  by  pieces  of  cotton  wool  lubricated 
with  boracic  vaseline  or  some  other  pure  fat. 

Infection  may  also  begin  in  the  skin  of  the  new-born 
infant  which  demands  therefore  special  care.  When  re- 
moving the  vernix  caseosa,  at  the  first  bath,  care  must 
be  taken  not  to  cause  any  injury  to  the  skin.  If  there 
is  a  cutaneous  wound,  it  should  be  protected  by  a  dressing 
and  should  be  watched  so  that  steps  may  at  once  be  taken 
to  prevent  its  extension  if  inflammation  sets  in.  A  daily 
bath  is  a  great  protection  against  erythematous,  pustular 
and  ulcerative  eruptions  on  the  skin  which  may  be  the 
starting  point  for  a  general  infection  especially  when  the 
eruption  appears  in  the  perineum.  Further  preventive 
measures  consist  in  changing  frequently  the  diapers  so 
that  faeces  and  urine  may  not  remain  in  contact  with  the 
delicate  skin,  and  that  the  microbes  contained  in  the  faeces 
may  be  removed  from  the  skin.  The  kind  of  linen  used 
and  the  way  in  which  the  diaper  is  put  on  are  also  im- 
portant, because  the  skin  is  mechanically  irritated  when 
the  linen  is  coarse  and  fastened  tightly.  Linen  soaked 
with  urine  should  not  be  used  again  after  merely  drying 
it ;  the  chemical  products  and  the  bacteria  of  the  urine 
would  both  irritate  the  skin.  "When  washing  the  anal 
and  genital  regions  rough  handling  is  apt  to  cause  wounds 
and  infection ;  it  is  best  to  wash  these  parts  with  pieces 
of  cotton  wool  dipped  into  lukewarm  boiled  water  and  then 
to  mop  the  parts  with  dry  cotton  wool.  The  cotton  wool 
should  be  kept  wrapped  up  in  a  clean  cloth  or  in  a  box, 
and  a  fresh  piece  should  be  used  each  time.  Even  greater 
care  is  required  when  there  is  any  eczematous  eruption ; 
it  should  be  treated  at  once,  and  some  protective  material 
should  be  used  to  prevent  the  infection  from  becoming 
more  extensive  and  deep.  In  bathing  the  child  cleanse 
the  skin  and  remove  all  secretions  which  have  accumulated 
between  the  fold  of  the  skin,  especially  at  the  neck, 
axillae,  and  groins  in  fat  children.  If  allowed  to  remain 
the  secretion  softens  the  skin  and  produces  intertigo  which 
may  develop  into  a  wide  spreading  inflammation  of  the 
skin  or  even  into  general  infection.     The  secretion  should 

420 


THE  PEEVENTION  OF  THE  DISEASES  OF  CHILDREN 

be  carefully  but  thoroughly  removed  and  a  piece  of  cotton 
wool  placed  in  the  folds  to  prevent  friction  between  the 
two  adjacent  surfaces.  A  careful  look  out  must  be  kept 
for  the  many  different  nodular,  pustular,  and  ulcerative 
eruptions  which  may  appear  on  the  skin  of  the  infant. 
"When  pus  is  present,  especially  in  the  diseases  accompanied 
by  the  formation  of  pustules  or  by  superficial  and  deep 
abscesses,  preventive  treatment  consists  in  antiseptic  com- 
presses and  dressings  and  early  evacuation  of  the  pus.  It 
is  obvious  that  the  physician's  hands  should  be  thoroughly 
cleansed  both  before  and  after  dressing  the  patient  ;  that 
soiled  dressings  should  be  at  once  destroyed  ;  and  that  the 
sick  child  should  be  isolated  from  the  other  children  of 
the  family.  In  institutions  perfect  isolation  of  these  cases 
is  most  essential  and  should  be  strictly  carried  out.  "What 
has  been  said  applies  also  to  erysipelas  and  to  cellulitis. 
The  possibility  of  the  conveyance  of  infection  by  soiled 
linen  or  by  the  utensils  and  bath,  etc.,  used  for  the  child 
must  be  remembered,  and  especial  care  be  taken  for  its 
prevention. 

Infection  may  also  arise  at  the  anus,  either  by  extension 
from  inflammations  of  the  adjacent  skin,  or  directly 
as  from  fissures  or  ulceration  of  the  mucous  membrane 
at  the  lower  end  of  the  rectum,  but  these  cases  are 
comparatively  rare.  Prevention  consists  in  careful  treat- 
ment of  any  inflammation  in  the  vicinity  of  the  anus, 
in  care  when  washing  the  perineum  and  in  regulating 
the  evacuations  of  the  bowels,  because,  as  will  be  later 
pointed  out,  the  nature  and  number  of  the  evacuations 
may  also  be  a  cause  of  these  inflammations. 

Lastly,  mention  must  be  made  of  the  genital  organs, 
especially  in  the  female,  which  apart  from  the  infective 
processes  already  described  may  be  the  seat  of  catarrhal, 
suppurative,  and  even  gangrenous  processes  mostly  caused 
by  some  local  infection.  Here,  too,  absolute  cleanliness 
and  the  avoidance  of  an}^  mechanical  irritation,  or  soften- 
ing of  the  skin  by  urine  and  faeces  are  of  great  importance. 
The  extension  of  inflammation  from  adjacent  parts  of  the 
skin,   and  the  importation  of  germs  from   other   parts  of 

421 


THE  PEEVENTION  OF  DISEASE 

the   body   or   from   the   outside,    are    also    of    the   utmost 
moment.     Dried  secretions  or  masses  of  epithelium  cast  off 
by  the  vigorous  desquamation  of  the  first  few  days  of  life 
should   be   removed   by   washing    and    the    parts    should 
afterwards  be  dabbed  with  dry  cotton  wool.      When  in- 
flammation of  the  genitals  already  exists  the  chief    aim 
of  prophylactic  treatment  is  to  prevent  the  extension  of 
the  mischief  and  to  heal  quickly  the  local  inflammation. 
The  principal  ways  in  which  infection  may  enter  the  body 
of   the  new-born  infant  have   now   been   considered,    and 
their  prevention  explained,  and  I  will  add   a  few   words 
about  the  nursery  considered  in  its  relation  to   the   pre- 
vention of  disease.      The   room    selected   should  be   light, 
well  ventilated,   and  one  that  can  be    warmed  ;  the  floor 
should  be  such  that  it  can  be  easily  washed  ;  for  instance, 
it  may  be  varnished  or  covered  with  linoleum.     Furniture 
which   creates   or   collects    dust,  such  as  curtains    or   up- 
holstered  armchairs,  should  so  far  as  possible  be  avoided. 
The  cradle  should  be  made  of  material  which  can  easily 
be  cleaned  and  there  should  be  at  least  two  sets  of  bedding 
so  that  it  may  be  possible  to  change  it  completely  in  case 
of  need.     "Washing  soiled  diapers  and  drying  them  in  the 
nursery  is  altogether  to  be  condemned,  and  in  institutions 
I  regard  the  correct  disposal  of  the  excreta  and  washing 
of  soiled  linen  as  most    important   factors    in   preventive 
measures.     It   seems  to  me  to  be  best  to  put   the   soiled 
diapers  and  soiled  linen,  or  linen  which  has  been  changed 
for  some  other  reason,  at  once  into  a  covered  vessel  kept 
in  the  room  and  containing  a  solution  of  corrosive  subli- 
mate (1  part  in  2,000) ;  this  will  not  injure  the  linen  and  the 
clothes  can  remain  in  it  till  they  are  afterwards  washed. 
This  is  the  safest  way  of  preventing  germs  from  getting 
into  the  air,   whether  from  dried  excreta  or   from  liquid 
faeces ;  and  at  the  same  time  this  treatment  of  the  linen 
serves  to  disinfect  the  faeces  and  they  are  made  innocuous 
by  the  antiseptic  and  may  be  poured  down   the    water- 
closet    directly   the    linen    has    been    removed   from    the 
vessel. 

Thermometers  are  a  further  source  of  infection  ;    they 

422 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

should  be  put  into  a  strong  solution  of  potassium  per- 
manganate after  use  and  be  rubbed  dry  and  smeared 
with  a  pure  fatty  substance  such  as  vaseline  (which  is 
kept  in  a  closed  jar)  before  being  used  again.  In  new- 
born infants  the  temperature  is  almost  invariably  taken 
in  the  rectum  and  germs  can  thus  be  readily  conveyed ; 
new  thermometers  should  therefore  be  used.  In  institu- 
tions a  special  thermometer  should  be  kept  for  each  child, 
which  can  be  destroyed  after  it  has  been  used  for  any 
infectious  case,  because  reliable  disinfection  of  the  in- 
strument cannot  be  attained  even  by  the  method  above 
described.  These  apparently  trivial  details  are  in  reality 
most  important,  and  it  must  not  be  thought  absurd  that 
I  refer  to  them  emphatically  and  at  some  length. 

Opinions  differ  as  to  the  possibility  of  infection  through 
the  air ;  my  own  experience  has  taught  me  to  regard 
this  as  possible,  so  that  in  addition  to  infection  by  contact 
I  ascribe  an  important  role  to  infection  by  the  air.  In 
institutions,  especially  when  there  is  not  sufficient  room 
and  the  place  is  over-filled  and  difficult  to  ventilate  and 
to  clean,  this  is  a  much  more  important  factor  than  in 
private  houses  where,  indeed,  it  is  only  in  the  lowest 
classes  that  the  squalor  and  the  large  number  of  children 
exercise  a  baneful  influence.  The  experience  of  hospitals 
conducted  upon  modern  hygienic  principles  and  of  found- 
ling-hospitals has  shown  that  much  can  be  done  in  this 
matter  by  adequate  hygienic  precautions.  A  sufficient 
number  of  light,  airy  large  rooms  with  but  few  patients 
in  each  room  must  be  provided,  the  floors,  ceilings  and 
walls  must  be  easily  cleaned ;  smaller  rooms  must  exist 
for  isolating  infants  suffering  from  infectious  disorders. 
It  should  be  possible  to  use  the  rooms  in  turn  and  to 
disinfect  them  thoroughly  in  the  interim.  There  should 
be  special  attendants  for  the  different  classes  of  disease. 
It  is  self-evident  that  in  private  houses,  too,  adequate 
ventilation  and  thorough  cleaning  of  the  nursery  are  re- 
quired, and  all  unnecessary  raising  of  dust  should  be 
avoided  as  by  using  damp  cloths  for  dusting  and  the  child 
should  be  in  another  room  while  the  cleaning  is  done. 

423 


THE   PEEVENTION   OF   DISEASE 

Some  of  the  preventive  measures  recommended  in  the 
foregoing  apply  also  to  older  children,  for  there  is  no  sharp 
line  of  demarcation  in  this  respect,  and  certain  ordinary- 
hygienic  and  prophylactic  principles  are  true  for  all 
pathological  conditions.  Nevertheless,  during  the  first 
few  days  of  life  there  is  a  greater  suscejDtibility  to  the 
injurious  action  of  bacteria  from  without,  to  the  transition 
from  a  latent  to  an  active  state  of  the  micro-organisms 
which  get  lodged  in  the  various  cavities  of  the  body,  and 
to  general  infective  processes  which  are  then  very  com- 
mon. Preventive  measures  are  therefore  more  urgently 
needed  than  at  other  times  and  for  this  reason  I  have 
entered  fully  into  them  here.  Premature  children  are 
very  susceptible  to  infection  of  every  kind  and  need  very 
special  attention ;  the  apparatus  used  to  produce  artificial 
warmth  for  them  such  as  incubators  must  be  thoroughly 
disinfected  after  each  time  it  is  used  ;  but  the  skin  must 
not  be  made  too  hot  by  these  or  by  the  use  of  hot-water 
bottles,  otherwise  irritation  of  the  skin  is  readily  set  up 
and  it  may  then  be  invaded  by  bacteria. 

PREVENTIVE    TREATMENT  DURING    INEANCY 

In  the  introductory  paragraphs  I  pointed  out  that  a 
certain  number  of  morbid  processes  are  especially  rife 
during  this  period  of  life  ;  and  foremost  among  these  are 
the  very  fatal  diseases  of  the  gastro-intestinal  tract.  We 
shall  therefore  begin  with  the  measures  which  can  be 
taken  to  prevent  an  attack  of  these  disorders ;  next  we 
shall  consider  the  prevention  of  complications,  and  lastly, 
the  measures  required  to  check  the  spread  of  the  disease. 
And  here  the  hygiene  of  the  feeding  of  infants  coincides 
to  a  great  extent  with  the  preventive  measures  required 
and  it  becomes  necessary  to  sketch  its  main  outlines. 

We  cannot  too  often  or  too  forcibly  emphasize  the 
principle  that,  with  very  rare  exceptions,  the  infant 
thrives  best  when  it  is  breast-fed  by  its  own  mother  and 
in  accordance  with  rational  rules.  The  endeavour  to 
spread  this  principle  must  be  made  not  only  by  the  family 

424 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

doctor  whose  advice  is  often  not  songht  or  is  souglit  too 
late,  but  by  all  who  have  an  opportunity  of  giving  advice 
in  this  matter.  I  am  aware — indeed  no  unprejudiced 
observer  can  close  his  eyes  to  the  fact — that  in  certain 
sections  of  the  population  the  modern  ways  of  living  and 
claims  of  life  have  during  the  past  few  years  acted 
against  the  nursing  of  infants  by  their  mothers  ;  on  the 
other  hand,  if  we  can  enlist  the  active  help  of  those  to 
whom  reference  has  been  made  above,  I  do  not  think  that 
it  is  too  late  to  bring  about  a  great  change  in  this  matter 
and  to  secure  for  coming  generations  of  children  their 
natural  source  of  nourishment.  The  subject  must  not 
only  be  treated  as  an  ethical  question  but  also  as  one  of 
preventive  treatment  in  connection  with  the  feeding 
and  rearing  of  infants  with  far-reaching  results.  The 
colostrum  found  in  the  breast  during  the  first  few  days 
after  delivery  fulfils  the  double  object  of  preparing  the 
stomach  of  the  new-born  infant  both  quantitatively  and 
qualitatively  for  the  breast  milk  and  of  promoting  the 
expulsion  of  meconium  contained  in  the  intestines,  and  it 
may  be  assumed  a  priori  that  a  mammary  gland  which 
has  grown  to  maturity  consecutively  with  the  growth  of 
the  foetus  and  which  has  derived  its  materials  from  the 
same  source  as  that  for  the  foetus,  namely,  the  maternal 
blood,  will  satisfy  the  individual  requirements  of  the  child 
more  exactly  than  will  the  milk  of  a  wet  nurse  however 
carefully  she  may  have  been  selected  after  consideration 
of  all  necessary  factors.  There  are  certain  vital  tendencies 
which  make  for  the  preservation  of  the  infant,  such  as 
the  immunity  against  certain  infectious  diseases,  which 
is  imparted  to  the  infant  in  utero  by  way  of  the  placental 
blood  stream,  and  experiments  and  statistics  during  the 
last  few  years  have  conclusively  shown  that  such  tendencies 
are  also  transmitted  through  the  milk  to  the  offspring. 
That  there  are  individual  characteristics  in  the  milk  of 
different  women  is  shown  by  the  fact  that  many  a  child 
which  is  perfectly  normal  and  physically  well  developed 
does  not  thrive  upon  the  milk  of  one  wet  nurse,  though 
examination  can  detect  nothing   wrong  in  her,   and  that 

425 


THE  PEEVENTION  OE  DISEASE 

tlie  same  cliilcl  will  thrive  perfectly  upon  tlie  railk  of 
anotlier  wet  nurse,  ttLOugh  tlie  other  circumstances  have 
remained  unchanged.  It  is  quite  conceivable  that  the 
characteristics  of  the  mother's  milk  are  those  which  best 
fulfil  the  conditions  required  by  her  offspring.  In  short, 
there  are  many  reasons  why  the  mother  should  nurse  her 
own  child  and  very  few  why  she  should  not,  and  we  need  be 
much  less  strict  about  the  conditions  which  fit  a  mother 
to  nurse  her  child  than  about  those  which  fit  a  wet  nurse. 
The  only  cases  in  which,  according  to  my  opinion,  we 
may  deviate  from  this  rule  are  cases  of  profound  anaemia, 
tuberculosis,  cardiac  disease,  and  ^predisposition  to  neuros- 
thenia  which  is  unfortunately  so  common ;  also  cases 
where  the  nipj)les  remain  undeveloped  in  spite  of  every- 
thing that  can  be  done  during  pregnancy  to  improve  them, 
and  lastly,  cases  in  which  an  inadequate  supply  of  milk 
which  is  generally  also  poor  in  quality  cannot  be  increased 
in  quantity  by  suitable  food  and  by  giving  the  breast 
to  the  child.  And  yet  we  have  seen,  too,  that  by  per- 
severance, a  sufficient  milk  supply  has  been  established 
in  women  who  were  apparently  delicate  and  not  looked 
upon  as  able  to  nurse  their  infants.  E-ules  of  hygiene 
are  necessary  for  the  mother  as  well  as  for  the  child  ;  the 
mother's  food  should  be  abundant,  and  easily  digestible,  but 
she  should  not,  as  so  often  happens,  be  overfed — this  will 
only  cause  digestive  disturbances  which  re-act  unfavour- 
ably upon  the  production  of  milk  and  will  not  increase 
the  fat  or  the  quantity  of  milk.  Mental  rest  and  the 
indifference  which  is  often  found  to  an  unwished  for  degree 
in  hired  wet  nurses  are  rare  in  the  young  women  of  our 
generation,  and  yet  are  of  extreme  value  for  the  child, 
and  much  as  I  value  the  use  of  scales,  and  advocate 
regular  weighing  of  the  infant,  yet  I  cannot  deny  that 
this  has  a  disadvantage  when  in  the  hands  of  nursing 
mothers  whose  minds  are  filled  with  teachings  promulgated 
by  popular  works,  and  who  become  mentally  depressed 
when  the  infant's  weight  is  at  a  standstill  or  when  its 
increase  in  weight  on  any  given  day  is  below  that  men- 
tioned in  these  books  ;  this  mental  depression  is  not  without 

426 


THE  PREVENTION  OP  THE  DISEASES  OF  CHILDREN 

its  influence  upon  the  growth  of  the  child.  When  the 
physician  knows  that  there  is  this  nervous  disposition  in 
the  mother,  or  as  soon  as  he  discovers  it,  he  will  do  well 
to  have  the  child  weighed  as  seldom  as  possible,  that  the 
weight  may  be  distributed  over  longer  periods,  and  may 
even  himself  weigh  the  infant ;  a  small  falsification  of  the 
result  in  these  cases  comes  under  the  category  of  pious 
frauds — in  short  he  must  do  what  will  be  for  the  interest 
of  both  child  and  mother. 

The  condition  of  the  nipples  and  breasts  requires  great 
attention,  especially  with  the  first  child.  The  shape  of 
the  nipple  should  be  improved  during  pregnancy  by  con- 
stantly drawing  it  out  with  a  breast-pumj)  and  it  should 
be  hardened  by  washing  with  spirit,  because  fissures  of 
the  nipple  often  make  the  work  of  nursing  the  infant 
impossible  or  very  difficult,  partly  through  the  pain  caused 
by  suckling  and  partly  through  the  possibility  of  infection, 
both  of  the  mouth  of  the  infant  and  of  the  breast 
itself.  The  nipple  should  be  washed  before  and  after  the 
child  has  the  breast,  and  there  is  then,  as  has  already  been 
mentioned,  no  necessity  for  washing  out  the  mouth  of  a 
breast-fed  infant.  When  there  is  suppurative  infiammation 
of  the  breast,  I  am  strongly  ojDposed  to  putting  the  child 
to  the  breast,  even  though  there  be  no  apparent  com- 
munication between  the  abscess  and  the  galactiferous  ducts ; 
the  constant  irritation  caused  by  the  suckling  can  only 
increase  the  infiammation  and  may  bring  about  the  com- 
munication which  did  not  exist  at  first  and  expose  the 
infant  to  the  serious  risk  of  direct  absorption  of  the  in- 
fected milk.  In  these  cases  it  generally  suffices  to  use 
the  other  breast  only,  and  this  sometimes  undergoes  com- 
pensatory hypertrophy,  or  if  the  child  is  old  enough  it 
may  be  fed  partly  by  hand  ;  or  if  it  is  only  a  few  weeks 
old  a  wet  nurse  should  be  recommended. 

The  number  of  meals  and  the  quantity  at  each  require 
the  greatest  attention ;  the  soundness  of  the  digestive 
apparatus  of  the  child  depends  mainly  ujion  a  correct 
regime,  and  mistakes  made  in  this  matter  cause  suffering 
not  only  during  the  whole  suckling  period  but  often  also' 

427 


THE  PREVENTION   OF  DISEASE 

ill  later  life.  A  feed  should  be  given  every  three  hours 
and  only  one  breast  given  at  each  feed  ;  there  should  be 
intervals  of  six  to  eight  hours  during  the  night  which  are 
important  also  for  the  mother  and  her  nursing  powers. 
These  are  the  general  principles  and  they  should  not  be 
departed  from,  in  one  or  other  direction,  except  in  special 
cases  where  the  condition  of  the  child  seems  to  make  it 
necessary.  The  dyspepsia  arising  from  overfeeding  of  the 
infant,  often  underestimated  and  occurring  even  in  breast- 
fed infants,  is  the  frequent  cause  of  severe  gastro-intestinal 
trouble.  Not  rarely  it  induces  the  development  of  con- 
stitutional maladies,  and  it  prepares  the  way  for  other 
diseases,  and  yet  the  point  most  to  be  emphasized  here  is 
that  it  is  j)i'eventible.  These  facts  make  it  desirable  that 
the  advice  of  the  physician  should  be  given  even  for  the 
healthy  child  ;  indeed,  the  object  of  preventive  treatment 
is  to  restrict  disease  to  an  irreducible  minimum  by  rational 
living  and  education.  To  judge  correctly  of  any  of  the 
abovenamed  conditions  the  physician  must  be  certain  too 
when  the  child  is  suffering  from  insufEcient  food,  if  breast- 
fed. Such  cases  are  on  the  whole  rarer  than  the  converse 
cases,  yet  they  do  occur  and  require  a  very  different  treat- 
ment. By  weighing  the  infant  before  and  after  feeding, 
by  estimating  the  quantity  of  urine,  the  state  of  the  faeces, 
the  distension  of  the  abdomen,  the  condition  of  the  mother's 
breasts  during  the  intervals  between  two  feeds  and  other 
such  points,  it  is  possible  to  arrive  at  a  correct  decision, 
and  according  to  the  circumstances  either  increase  the  food 
or  change  the  nurse.  I  will  pass  on  and  consider  the 
question  of  suckling  by  a  wet  nurse.  And  I  will  begin 
with  a  few  words  about  ethical  considerations  and  ob- 
jections raised  on  several  sides.  The  neglect  to  which  the 
wet  nurse's  own  child  is  exposed,  when  she  goes  out  to 
nurse  another's  child,  has  been  pointed  out ;  this  objection 
is,  in  my  opinion,  not  ver}'-  great,  seeing  that  we  do  not 
generall}^  engage  a  wet  nurse  till  two  or  three  months 
after  her  deliver}^,  and  as  it  is  the  custom  in  Germany  for 
the  lower  clashes  to  begin  to  feed  their  children  by  hand 
at  that  age    there  is    no    s^Dscial    risk    in    weaning    these 

428 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

children.  We  may  assume  too  that  if  the  woman  did  not 
go  out  as  a  wet  nurse  she  would  have  to  go  out  to  other 
work  which  would  take  her  altogether  away  from  her  own 
child  or  at  any  rate  would  take  her  away  during  the 
daytime  and  her  child  would  be  no  better  off.  There  is 
no  doubt  in  the  mind  of  any  physician  as  to  the  fact 
that  the  milk  of  a  good  wet  nurse  gives  better  results 
than  the  most  rational  and  scientific  hand  feeding  ;  on  the 
other  hand,  it  is  equally  certain,  for  reasons  "stated  above, 
that  the  mother's  milk  is  far  better  for  her  child  than 
that  of  any  wet  nurse.  I  will  briefly  refer  to  the  question 
of  the  selection  of  a  wet  nurse  limiting  myself  to  points 
which  are  absolutely  necessary.  It  is  evident  that  with 
a  wet  nurse  we  must  insist  upon  qualities  and  conditions 
upon  Avhich  we  should  not  lay  so  great  stress  if  a  mother 
were  nursing  her  own  child.  The  wet  nurse  should  be 
thoroughly  examined  to  see  that  she  is  healthy  ;  she  should 
be  between  twenty  and  thirty  years  of  age,  her  breasts 
and  nipples  well-formed,  with  plenty  of  milk.  It  is  always 
an  advantage  and  in  suspicious  cases  it  is  even  essential 
to  see  the  nurse's  own  child  and  judge  of  its  state  of 
health  and  development ;  on  the  other  hand,  not  much 
importance  need  be  attached  to  the  natural  disposition  or 
colour  of  the  hair  of  the  nurse,  the  diet  of  the  wet 
nurse  must  not  be  suddenly  changed  from  the  simple  poor 
diet  to  which  she  has  been  accustomed,  to  the  rich  abundant 
meat  diet  of  the  household  of  which  she  now  forms  part. 
Do  not  give  much  meat  to  those  who  have  been  accustomed 
to  a  diet  largely  consisting  of  vegetables  ;  do  not  give 
them  too  much  liquid  or  compel  them  to  take  alcoholic 
beverages  when  they  have  not  been  accustomed  to  take 
alcohol.  Let  them  work  and  take  exercise  to  prevent  them 
from  becoming  less  capable  physically  of  nursing  the  child. 
Watch  carefully  to  see  that  the  hours  fixed  for  the  infant's 
meals  are  regularly  adhered  to,  and  on  the  other  hand 
take  care  that  she  gives  the  child  no  other  food  when  she 
takes  her  own  meals.  The  mother's  constant  supervision 
is  needed  to  see  that  the  infant  is  well  cared  for,  otherwise 
it  may  easily  happen  that  instead  of  removing  wet  diapers, 

429 


THE   PREVENTION  OF  DISEASE 

wLicli  are  iiiiconif  or  table  and  cause  tlie  infant  to  cry,  the 
nnrse  will  quiet  the  child  by  putting  it  to  the  breast — a 
procedure  which  will  produce  those  dyspeptic  troubles  to 
which  I  referred  above  and  which  turn  a  peaceable  nursery 
into  a  pandemonium.  For  similar  reasons  the  wet  nurse 
should  never  be  allowed  to  go  out  alone  with  the  child  ; 
her  lack  of  knowledge  induces  her  to  cover  up  the  infant 
when  it  is  out  of  doors  and  it  runs  a  greater  risk  of 
taking  cold  afterwards.  The  mother  should  always  herself 
bathe  the  child  and  look  after  the  cleansing  of  the  nose 
and  ears,  otherwise  harmful  results  may  follow.  In  short, 
one  must  not  rely  upon  this  stranger  in  any  way  and  the 
physician  must  impress  upon  the  mother  the  great  necessity 
for  supervision. 

Further,  the  infant  must  never  sleep  in  the  bed  with  an 
adult,  not  even  with  the  nurse,  partly  for  hygienic  reasons, 
partly  because  of  the  danger  of  overlaying.  When  possi- 
ble the  wet  nurse  should  sleep  in  the  room  adjoining  the 
nursery,  so  that  the  air  may  not  be  necessarily  contami- 
nated, and  if  she  is  wanted  at  night  she  can  be  called. 
Her  physical  health  must  not  be  neglected,  because  dis- 
turbances of  physical  functions  react  upon  the  infant  and 
may  cause  very  unpleasant  disorders.  In  case  of  any 
serious  illness  in  the  nurse,  our  action  must  be  according 
to  the  nature  of  the  illness.  Temporary  indisposition, 
even  when  of  infectious  nature,  such  as  acute  tonsilitis,  is 
not  a  sufificient  reason  for  taking  the  child  from  the  breast ; 
the  breast  should  still  be  given,  but  in  the  intervals  be- 
tween feeding  the  infant  should  not  be  with  the  nurse. 
An  illness  which  will  be  of  longer  duration  or  one  which 
is  readily  communicable  is  a  sufficient  reason  for  taking 
the  child  from  the  breast,  even  though  there  may  be  no 
experimental  proof  that  the  milk  is  affected  ;  as  a  rule, 
changes  soon  appear  in  the  secretion  of  milk  which  make 
suckling  impossible.  On  the  other  hand  catarrhs,  indiges- 
tion and  similar  indispositions  afford  no  valid  reason  for 
making  any  change,  but  these  ailments  should  be  cured  by 
remedies  which  do  not  pass  into  the  milk  and  so  injure  the 
infant.       There   need  be  no  fear  if    menstruation    should 

430 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

begin  again,  for  even  if,  as  Schlichter  maintains,  the  in- 
fant does  not  thrive  quite  so  well  during  the  menstrual 
period  and  often  exhibits  some  disturbance,  always  trivial, 
yet  the  disturbances  are  quite  transient.  '  The  recommence- 
ment of  menstruation  is  harmful  because  it  makes  a 
fresh  conception  more  possible,  and  the  changes  in  the 
milk  secretion  produced  by  conception  prohibit  further 
suckling. 

Without  separately  considering  the  different  forms  of 
mixed  diet,  such  as  are  especially  preferred  by  the  French, 
I  will  at  once  proceed  to  the  subject  of  the  artificial  feed- 
ing of  infants.  There  is  danger  for  the  infant  which  is 
unwisely  fed  even  though  its  food  be  derived  from  the 
mother's  breasts  or  from  the  wet  nurse,  but  these  dangers 
are  rarely  great  enough  to  imperil  its  life.  Conditions  are 
however  very  different  in  a  hand  fed  infant,  and  these 
dangers  are  enormously  increased.  It  must  be  clearly 
understood,  in  spite  of  all  assurances  to  the  contrary,  that 
the  artificial  feeding  of  the  infant  from  its  birth  deprives 
it  of  many  advantages  to  which  reference  has  been  made 
above,  and  is  also  one  of  the  most  difficult  and  troublesome 
problems.  Cow's  milk  is  most  frequently  used,  and  we  shall 
first  consider  the  dangers  connected  with  it.  They  may  be 
regarded  from  three  aspects  :  the  chemical,  the  bacterio- 
logical and  the  quantitative.  As  to  the  chemical,  not 
only  do  we  know  the  difference  in  percentage  composition 
between  the  two,  but  work  done  during  recent  years  in 
various  directions  has  shown  us  also  what  are  the  differ- 
ences in  the  elementary  structure  between  human  milk  and 
cow's  milk.  And  now  we  know  that  cow's  milk  contains 
about  twice  as  much  proteid,  and  about  half  the  quantity 
of  milk  sugar  and  more  fat  and  more  salts  than  human 
milk ;  the  casein  derived  from  cow's  milk  is  far  less  suitable 
for  the  infant  than  that  from  human  milk  ;  and  the  rela- 
tion between  the  nitrogenous  and  the  non-nitrogenous 
constituents  of  cow's  milk  is  one  which  is  far  less  adapted 
to  the  requirements  of  the  growing  infant  than  that  in 
human  milk.  "We  are  also  now  well  informed  about  the 
difference  in  the  eleinentary  structure  between  casein  from 

431 


THE  PREVENTION  OF  DISEASE 

cow's  milk  and  from  human  milk,  about  the  constitution 
of  the  different  fats  in  milk,  and  the  solubility  of  the  salts, 
and  have  come  to  the  conclusion  that  the  most  careful 
calculations  and  attempts  to  make  cow's  milk  similar  in 
constitution  to  human  milk  must  all  fail  because  we  are 
working  with  substances  differing  chemically.  Apart 
from  these  facts  we  have  in  human  milk  a  food  the 
quantity  and  composition  of  which  are  adapted  to  the 
requirements  of  the  child  at  different  periods,  while  with 
cow's  milk  we  can  attain  only  a  certain  average  composi- 
tion, and  the  infant's  intestinal  tract  must  first  adapt 
itself  to  be  able  to  digest  this.  There  are  also  other 
factors :  the  difference  in  coagulability  and  capacity  for 
absorption  of  the  casein,  the  totally  different  mode  of 
absorption  of  the  fat,  the  absence  from  cow's  milk  of 
certain  substances,  such  as  nuclein  and  lecithin,  the  de- 
ficiency in  iron,  the  great  capacity  exhibited  by  the  salts 
in  cow's  milk  for  combining  with  the  hydrochloric  acid  of 
the  stomach — all  these  make  increased  demands  upon  the 
digestive  apparatus,  and  we  can  never  tell  beforehand  that 
the  intestinal  tract  of  the  infant  will  adapt  itself  to  these 
conditions,  and  that  there  will  not  be  a  deficiency  in  the 
materials  required  for  building  up  certain  tissues.  For 
these  reasons,  in  spite  of  every  precaution  which  can  be 
taken  against  accidental  disturbances,  and  in  spite  of 
absolute  cleanliness  and  regularity  in  feeding,  dyspepsia 
often  arises  in  children  brought  up  on  cow's  milk — almost 
a  physiological  dyspepsia — and  lays  the  foundation  for 
serious  gastro-intestinal  disturbances  which  may  set  in 
with  astonishing  rapidity  and  severity.  Many  attempts 
have  been  made  to  lessen  these  dangers,  and  we  have 
succeeded  in  obtaining  a  number  of  preparations  and 
modifications  of  cow's  milk  in  which  the  chemically  in- 
jurious effects  of  ordinary  cow's  milk  have  been  to  a  cer- 
tain extent  overcome,  but  these  products  are  far  inferior 
to  human  milk  in  fitness  as  a  perfect  food  ;  for  human 
milk  gives  rise  to  no  troubles  and  assures  the  steady  and 
satisfactory  development  of  the  infant.  This  fact  must  be 
firmly  grasped,  so  that  we  can  state  the  objections  against 

432 


THE  PREVENTION  OF  THE  DISEASES  OE  CHILDREN 

these  artificial  foods,  and  on  the  other  hand  watch  very 
carefully  for  the  slighest  digestive  trouble,  and  treat  it 
correctly  at  the  very  beginning. 

A  second  class  of  injurious  effects  arises  from  bacterio- 
logical infection,  and  here,  although  we  have  to  deal  with 
a  large  number  of  opinions,  we  have  not  yet  reached  any 
definite  conclusion.  I  will  rapidly  pass  over  the  fact  that 
the  mother's  milk  and  the  nurse's  milk  are  unboiled,  while 
cow's  milk  is  frequently  given  to  the  infant  after  the 
milk  has  been  boiled,  and  that  the  boiling  causes  a  modifi- 
cation in  the  nitrogenous  constituents  and  salts  which 
renders  the  milk  less  digestible.  This  cannot  be  avoided, 
and  Biedert's  idea  of  getting  cow's  milk  in  an  aseptic  state 
and  using  it  unboiled  is  at  present  a  somewhat  impracticable 
suggestion.  The  danger  of  transmission  of  tuberculosis,  or 
of  foot  and  mouth  disease,  has  been  considerably  minimised 
during  the  last  few  years  by  the  greater  attention  devoted 
to  the  examination  of  cows  by  farmers  and  owners  of  dairies, 
and  by  the  destruction  of  pathogenic  microbes  by  boiling 
the  milk, 

Recently  it  has  been  proposed  to  so  heat  ^  the  milk  that 
its  flavour  may  not  be  interfered  with.  I  must  refrain  at 
present  from  giving  an  opinion  in  respect  of  milk  so  treated, 
as  I  have  had  no  personal  experience  of  its  use.  Besides 
pathogenic  organisms  there  may  be  an  enormous  number  of 
bacteria  in  milk,  which  are  derived  from  the  dust  of  cow- 
sheds, the  excrements  of  the  animals,  the  hands  of  the 
milkers,  the  water  for  washing  the  milkpails,  the  cloths 
used  for  straining  the  milk,  and  from  the  many  utensils  into 
which  the  milk  may  be  put  before  it  reaches  the  consumer. 

These  micro-organisms  sometimes  cause  fermentation  of 
the  milk  sugar  with  the  formation  of  lactic  acid,  sometimes 
bring  about  changes  in  the  nitrogenous  substances  with 
the  formation  of  toxic  products,  and  in  other  cases  produce 
injurious  effects  in  the  digestive  apparatus  of  the  infant  by 
their  mere  presence. 

The    following    points    are    also    important :    the   com- 

^  The  author  is,  both  here  and  overleaf,  apparently  referring  to 
pasteurization. 

433  F  F 


THE   PREVENTION   OF   DISEASE 

binatiou  of  free  liydrochloric  acid  with  the  salts  of  cow's 
milk  and  the  loss  of  its  antiseptic  property,  the  formation 
of  other  acids  and  gases  in  the  stomach  of  the  hand-fed 
infant,  and  the  loss  of  tone  of  the  stomach  caused  by  the 
increased  work  and  over-distension.  This  loss  of  tone 
extends  also  to  the  intestines  where  it  manifests  itself  by 
enfeebled  peristaltic  action  and  an  altered  reaction  of  the 
intestinal  contents  in  children  brought  up  on  cow's  milk. 
When  we  consider  these  facts  it  becomes  obvious  that  we 
must  be  prepared  to  overcome  the  dangers  arising  from 
this  source.  This  has  led  to  the  introduction  of  processes 
for  the  sterilization  of  milk,  the  details  of  which  cannot  be 
here  given ;  suffice  it  to  say  that  too  great  reliance  must 
not  be  placed  upon  these  methods,  that  we  should  regard 
with  suspicion  milk  which  has  been  sterilized  in  the  cow- 
shed, and  further  that  the  quantity  to  be  sterilized  at  one 
time  should  not  exceed  the  quantity  needed  during  twenty- 
four  hours  in  winter  or  during  twelve  hours  in  summer, 
and  it  should  be  kept  at  a  temperature  below  45°  F.  before 
it  is  used.  As  further  precautions  we  may  mention  that 
milk  which  has  been  warmed  and  is  being  kept  warm 
artificially  by  being  wrapped  in  flannel  or  in  a  bottle  warmer 
should  not  be  taken  for  the  child  when  going  on  a  long 
journey.  The  feeding  bottles  must  be  kept  absolutely  clean, 
and  should  have  wide  necks  and  no  projecting  shoulders,  the 
teats  and  milk  vessels  should  be  clean,  as  also  should  the 
hands  of  those  who  have  to  deal  with  the  milk,  because 
pathogenic  germs  may  collect  under  the  nails  and  on  the 
skin  of  the  hands.  In  institutions  artificial  feeding  is  apt 
to  be  followed  by  very  bad  results,  and  therefore  in  these 
places  greater  stress  still  must  be  laid  upon  all  precautionary 
measures ;  the  dangers  are  greatly  increased  because  of  the 
many  hands  through  which  the  milk  has  to  pass,  and  of  the 
possibility  of  infection  of  the  milk  by  virulent  germs  from 
the  air  of  the  wards  and  from  suppurative  processes. 

I  have  already  stated  that  I  regard  the  washing  of  the 
mouth  of  healthy  breast-fed  children  not  only  as  super- 
fluous but  as  injurious  in  certain  respects,  but  I  do  not  hold 
the  same  view  as  regards   infants   brought    up  by  hand. 

434 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

The  milk  j^irobably  already  contains  some  germs,  and  with 
the  regurgitation  of  food  into  the  mouth,  which  is  so  com- 
mon in  these  children,  large  flakes  of  casein  become  lodged 
in  the  cheeks  and  in  other  parts  from  which  they  cannot  be 
easily  dislodged  by  the  tongue,  thus  affording  a  suitable 
soil  for  numerous  microbes ;  and  for  this  reason  I  consider 
it  best  to  wash  out  the  mouth  gently  after  each  meal.  It 
must  be  done  very  carefully,  so  as  to  avoid  injuring  the 
mucous  membrane,  or  inducing  vomiting,  which  is  so  apt 
to  occur  in  these  infants  and  which  would  only  frustrate 
our  object. 

Further,  injurious  effects  in  feeding  with  cow's  milk 
arise  from  mechanical  overloading  of  the  stomach  and 
intestines.  They  include  the  ill  effects  of  the  dyspepsia 
caused  by  overfeeding,  together  with  other  evils  caused  by 
a  food  which  is  difficult  of  digestion,  often  contains  germs 
and  is  too  long  in  the  distended  digestive  tract. 

Provided  that  there  are  the  regular  intervals  between  the 
times  of  feeding,  and  that  the  mother's  breasts  and  nipples 
are  normal,  a  breast-fed  infant  takes  the  breast,  lets  go  the 
nipple  as  soon  as  its  hunger  is  appeased  and  generally  falls 
asleep.  The  act  of  sucking  the  breast  of  the  mother  or 
wet  nurse  is,  with  a  few  exceptions,  work  which  tires  the 
infant  and  induces  sleep ;  but  it  is  otherwise  with  a  child 
fed  on  cow's  milk.  The  short  tubeless  teats  of  feedino- 
bottles,  introduced  in  the  last  few  years  because  of  clean- 
liness and  almost  universally  used,  enable  the  milk  to  get 
into  the  stomach  with  very  little  effort  and  with  great 
rapidity.  Large  quantities  of  air  are  generally  sucked 
down  with  the  milk,  the  feeling  of  tiredness  after  doing 
work  does  not  set  in,  a  larger  quantity  of  milk  than  is 
required  gets  into  the  stomach  and  is  more  difficult  of 
digestion.  The  undue  delay  of  the  food  in  the  stomach 
and  the  abnormal  formation  of  gas  produce  atony  of  the 
walls  and  over-distension — conditions  well  known  to  every 
physician. 

The  close  connexion  between  gastric  and  intestinal 
digestion  and  the  rapid  extension  to  the  intestines  of  any 
gastric    disturbance    may  give   rise  to  intestinal  disorders 

435 


THE   PREVENTION   OF  DISEASE 

whicli  at  tlie  slightest  provocation  pass  into  tlie  severest 
forms  of  gastro-enteritis.  Contrivances  devised  to  imitate 
tlie  meclianisni  of  breast-feeding,  sucli  as  long  tubes  with 
valves  in  the  stopper  of  the  feeding  bottle,  or  valves  at 
the  sides  of  the  bottles,  answer  the  purpose  to  some 
extent,  but  have  the  disadvantage  of  making  it  difficult 
if  not  impossible  to  clean  the  apparatus  thoroughly,  and 
therefore  do  not  really  help.  It  is  better  to  give  a 
measured  quantity  of  milk  adapted  to  the  age,  weight 
and  size  of  the  infant,  in  accordance  with  tables  drawn  up 
by  different  authors,  the  best  of  which  are  Escherich's, 
based  upon  the  volumetric  method.  But  here  we  are  deal- 
ing only  with  averages,  and  it  becomes  difficult  to  individ- 
ualize for  any  given  case.  The  method  also  is  somewhat 
complex,  and  would  be  beyond  the  intellectual  grasp  of 
some  of  the  women  into  whose  hands  the  preparation  of 
the  infant's  food  is  entrusted.  We  must  remember  that 
the  rules  for  the  artificial  feeding  of  infants  have  to  be 
put  in  a  form  which  is  simple  enough  to  be  carried  out  by 
any  one. 

I  know  that  the  preceding  pronouncements  will  meet 
with  much  criticism,  especially  from  German  readers, 
and  that  my  views  about  the  difficulties  and  dangers 
arising  from  feeding  infants  on  cow's  milk  will  be 
regarded  as  much  exaggerated.  The  standpoint  I  take 
may  be  explained  by  the  fact  that  my  work  lies  in  a 
district  where  infants  are  suckled,  and  that  I  have  had 
many  opportunities  for  observing  the  very  great  differences 
between  these  results  and  those  obtained  from  the  methods 
of  artificial  feeding  described  above.  It  is  possible  that  the 
greater  personal  experience  and  the  greater  intelligence  of 
a  people  who  interest  themselves  more  in  this  matter,  and 
the  better  conditions  and  more  careful  preparation  of  the 
cow's  milk  which  result  from  this,  may  make  the  results 
more  favourable  than  they  are  with  us  in  the  country  ; 
yet  when  I  compare  the  rates  of  mortality  among  breast- 
fed and  artificially  fed  infants  and  note  how  insignificantly 
these  have  been  influenced,  in  spite  of  the  great  progress 
made  in  the  art  of  artificial  feeding  during  the  last  decade, 

436 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

I  am  forced  to  the  conclusion  that  the  statements  I  have 
made  are  for  the  most  part  not  exaggerated. 

After  the  various  preparations  of  cow's  milk,  we  must 
next  consider  condensed  milks  and  the  commercial  pro- 
ducts known  as  permanent  sterilized  milks.  They  have 
the  advantage  of  being  free  from  germs  when  they  reach 
the  consumer,  but  possess  a  number  of  other  bad  qualities. 
Some  contain  a  large  proportion  of  cane  sugar,  others  have 
a  disagreeable  flavour  and  if  used  exclusively  for  a  long 
time  are  said  to  produce  not  only  the  ill  effects  common  to 
all  methods  of  artificial  feeding,  but  also  to  cause  scurvy- 
rickets  (Barlow's  disease).  About  the  latter  I  have  no 
personal  experience,  as  the  disease  is  quite  unknown  in  this 
part  of  the  country. 

The  prepared  foods  for  children,  many  of  which  are 
already  in  the  market,  while  others  are  being  added  to  the 
list  almost  every  year,  possess  some  advantages.  They  are 
easy  to  prepare,  can  be  kept  a  long  time,  and  are  relatively 
free  from  germs.  On  the  other  hand  they  are  most  unsuit- 
able during  the  first  months  of  life,  because  the  child's 
powers  of  absorption  cannot  be  altered  ;  they  tend  to  cause 
obstinate  constipation  and  often  give  rise  to  severe  gastro- 
intestinal complaints. 

A  rational  hygiene  for  the  first  year  of  life,  the  object  of 
which  is  to  preserve  the  normal  condition  of  the  digestive 
organs  of  the  infant  and  to  ensure  the  satisfactory  develop- 
ment of  the  child,  must  include  a  decision  as  to  the  time 
when  a  breast-fed  infant  should  receive  additional  food,  and 
when  it  ought  to  be  weaned  from  the  breast.  I  will  briefly 
answer  this  question.  Food  should  be  given  in  addition  to 
the  breast  milk  when  failure  to  increase  in  weight  or  too 
small  a  weekly  increase  of  weight  for  some  time  shows  that 
the  mother's  milk  or  wet  nurse's  milk  is  insufficient.  This 
may  not  occur  till  relatively  quite  late,  and  there  are  many 
children  who  thrive  exceedingly  well  up  to  the  tenth  or 
twelfth  month  on  breast  milk  alone.  But  the  commencement 
of  the  second  half  year  of  life  seems  generally  to  be  the  time 
at  which  additional  food  is  required.  How  this  is  to  be  given 
cannot  further  be  detailed  in  this  place,  I  will  merely  point 

437 


THE  PREVENTION   OF  DISEASE 

out  tliat  a  gradual  and  slow  increase  of  food  is  more  rational 
and  less  dangerous  tlian  a  sudden  addition.  Concerning  tlie 
choice  of  food — my  custom  is  first  to  give  a  thin  soup  to  see 
■whether  the  child  can  take  any  additional  food  ;  later  breast- 
feeding once  a  day  will  be  sufficient,  and  pap  may  be  given, 
and  thus  the  infant  is  gradually  weaned  in  the  course  of 
two  or  three  months.  By  this  method  we  avoid  any  sudden 
change,  and  further  there  is  the  possibility  of  returning  to 
breast-feeding  if  digestive  disturbances  make  it  necessary. 

"What  has  been  said  about  additional  feeding  applies  also 
to  weaning,  indeed  the  former  is  only  to  prepare  for  the 
latter.  The  more  gradually  the  weaning  is  carried  out,  the 
fewer  will  be  the  dangers  arising  from  it.  We  can  gather 
no  physiological  rule  as  to  weaning  from  the  development 
of  the  infant ;  the  time  for  dentition  is  so  inconstant  and  is 
dependent  upon  so  many  factors  that  it  cannot  be  used  as 
our  guide.  The  same  is  true  of  the  change  which  shows 
that  the  limit  for  assimilation  of  milk  sugar  is  passed, 
which  cannot  in  practice  be  readily  enough  determined  to 
serve  us  as  a  guide.  That  whenever  possible  weaning 
should  not  be  postponed  to  the  hottest  season  of  the  year  is 
self  evident. 

I  have  already  stated  that  for  the  additional  feeding  of 
breast-fed  infants,  and  later  for  the  entire  feeding  of  the 
weaned  infant,  I  use  a  suitable  preparation  of  cow's  milk, 
soups  and  various  forms  of  pap.  Eggs  I  like  to  avoid  dur- 
ing the  first  year  of  life,  because  exact  experiments  have 
shown  me  that  diarrhoea,  with  very  ofi'ensive  motions,  has 
followed  the  use  of  eggs ;  and  meat,  even  when  hashed  or 
minced,  I  would  not  give  until  the  fourth  half  year  of  life, 
because  I  have  observed  a  number  of  cases  of  intestinal 
irritation  set  up  by  giving  meat  early.  These  are  not 
definite  rules  for  feeding,  but  merely  advice  one  can  give, 
and  parents  will  often  without  the  knowledge  and  consent 
of  the  physician  fail  to  carry  out  the  advice,  and  yet  the 
children  may  not  suffer  any  ill  effects.  On  the  other  hand, 
if  the  parents  have  been  told  of  the  dangers,  they  cannot 
blame  the  physician  if  ill  effects  do  result. 

It  is  now  time  to  end  this  long  chapter  about  diet  during 

438 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

infancy,  and  to  turn  our  attention  to  the  preventive  treat- 
ment, in  a  wider  sense,  of  intestinal  disorders.  And  here 
we  have  two  objects  in  view :  firstly,  to  prevent  further 
extension  of  the  disorder  by  adopting  treatment  at  the  very 
commencement  of  the  illness  ;  and  secondly,  by  suitable 
precautionary  measures  to  prevent  complications  from 
developing.  And  lastly,  especially  in  institutions,  we  must 
bear  in  mind  the  important  fact  that  a  number  of  these 
disorders  are  very  infectious,  and  we  must  do  our  utmost  to 
prevent  the  disease  spreading  to  others. 

Sufficient  stress  is  not  laid  upon  the  fact  that  gastro- 
intestinal disease  in  infants,  even  though  it  appear  as  a 
most  acute  process,  is  not  in  most  cases  really  so,  but 
develops  upon  a  soil  long  prepared  for  it  as  it  develops  after 
repeated  slight  attacks.  Just  as,  on  the  one  hand,  it  is 
possible  by  keeping  a  careful  watch  over  the  feeding  to 
prevent  the  greater  number  of  cases  of  digestive  troubles,  so 
too  it  is  possible  by  careful  observation  to  recognize  these 
minor  disturbances  or  alterations  in  the  digestive  process,  to 
remove  them  by  adequate  measures,  and  thus  to  prevent  an 
outbreak  of  more  severe  disease.  It  is  evident  that  this 
requires  an  exact  knowledge  of  the  physiology  of  digestion 
in  the  infant,  that  the  greatest  attention  should  be  given 
even  to  the  most  trivial  symptoms,  and  that  we  must  not 
rely  upon  the  increase  in  weight  alone,  because  the  weight 
may  be  quite  satisfactory  in  children  with  sHght  gastro- 
intestinal trouble.  The  serious  illness  which  often  quite 
unexpectedly  sets  in  with  great  intensity  and  rapidity,  and 
resists  all  treatment  or  proves  very  intractable,  places  the 
physician  in  a  very  difficult  position,  for  which  he  is  himself 
partly  to  blame.  We  should  therefore  pay  special  attention 
to  the  general  appearance  of  the  child — the  play  of  its  features, 
the  condition  of  the  buccal  mucous  membrane,  the  number 
and  nature  of  its  evacuations  and  its  sleej).  We  should 
note  also  the  vomit  if  such  occur,  the  state  of  distention  of 
the  abdomen,  the  condition  of  the  anal  region  and  the 
frequency  of  micturition.  These  various  points  cannot 
here  be  dealt  with  in  detail,  and  for  further  information  I 
would   refer   the   reader  to   the   excellent  article   by  Von 

439 


THE  PREVENTION  OF  DISEASE 

Epstein  in  the  "Handbook  of  Practical  Medicine."  These 
conditions  require  our  most  careful  attention,  and  immedi- 
ate treatment  of  them  will  generally  prevent  the  threatened 
gastro-enteritis.  That  this  is  a  very  grave  danger  in 
artificially  fed  children,  and  that  it  requires  greater  atten- 
tion than  the  physician  generally  bestows  upon  it,  is 
obvious  from  what  has  been  said  above.  Though,  at  this 
period  of  life,  the  most  serious  and  dangerous  digestive 
disorders  are  the  apparently  acute  disorders  which  set  in 
when  the  infant  appears  to  be  in  perfect  health,  yet  the 
most  troublesome  ones  which  the  physician  is  called  upon 
to  treat  are  those  chronic  digestive  disorders,  the  seeds  of 
which  were  sown  mostly  by  improper  feeding  and  by 
disregard  of  previous  premonitory  and  slight  digestive 
disturbances. 

Next  we  come  to  cases  where  the  disease  is  already  fully 
developed  and  where  prophylactic  treatment  is  required  to 
prevent  the  disease  from  becoming  general  and  to  prevent 
accidental  complications.  To  treat  this  subject  exhaust- 
ively would  compel  me  to  go  over  the  entire  field  of  the 
pathology  of  digestive  disorders  in  the  infant :  I  shall  there- 
fore restrict  myself  to  giving  a  few  examples.  The  first 
thing  to  be  done  is  to  expel  the  infective  material  from  the 
gastro-intestinal  tract,  or  to  render  it  innocuous,  to  remove 
fermenting  masses,  to  dilute  the  toxins,  and  to  bring 
about  conditions  which  are  not  favourable  to  the  growth 
of  intestinal  microbes.  These  indications  can  be  ful- 
filled by  the  mechanical  emptying  of  the  stomach  and 
intestines,  and  by  the  administration  of  harmless  liquids 
such  as  tea  or  boiled  water.  It  is  important  that  the 
mouth  should  be  kept  clean,  because  infective  processes 
may  spread  thence  to  adjacent  cavities,  to  the  salivary 
glands  or  downwards  to  the  oesophagus.  The  swallowing 
of  infected  secretions  should  be  prevented  because  it  may 
produce  disease  of  the  lungs.  The  skin  needs  careful 
attention,  because  infectious  processes  often  begin  in  the 
skin  and  thence  invade  the  body.  Diapers  soiled  with 
faeces  or  urine  should  at  once  be  removed  and  thoroughly 
disinfected   to   prevent   infectious    intestinal    germs    from 

440 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

getting  into  other  cavities  and  infecting  them.  The  great- 
est cleanliness  is  required  as  regards  the  hands  and  linen 
and  all  utensils  used  for  the  child.  Purity  of  the  air  in  the 
room  is  also  important,  and  other  similar  preventive 
measures  already  suggested  in  the  earlier  pages  should 
be  adopted. 

Very  special  ^precautions  are  needed  in  institutions,  for 
many  of  the  morbid  processes  considered  are  extremely  con- 
tagious and  readily  spread  to  the  greater  number  of  the 
children  kept  in  the  institution.  There  are  various  ways 
in  which  the  infection  is  spread,  all  of  which  should  be  kept 
in  mind.  It  is  safest  when  possible  to  isolate  these  cases 
completely,  and  to  appoint  special  attendants  for  them.  The 
diapers  and  child's  body  linen  should  be  disinfected  with  solu- 
tion of  corrosive  sublimate  and  then  washed  separately  from 
the  other  linen.  Each  patient  should  have  a  separate  ther- 
mometer and  bath.  The  feeding  bottle  and  teat  and  all 
utensils  used  in  preparing  the  milk  should  be  kept  separate 
from  the  rest.  After  a  death  has  occurred  from  such  a 
disease  the  room  and  all  its  contents  should  be  thoroughly 
disinfected,  and  infected  objects  should  be  destroyed.  If 
complete  isolation  of  these  children  is  impossible  the  cubicle 
system  may  be  tried,  which  was  introduced  into  the 
children's  hospital  at  Paris  by  Grancher.  Each  child  suffering 
from  an  infective  disease  is  in  a  small  cubicle  separated  off 
by  curtains  from  the  rest  of  the  ward  ;  all  utensils  used  for  it 
are  kept  in  the  cubicle ;  and  the  child  is  attended  to  by  one 
special  nurse.  The  physician  wears  a  linen  overall,  and 
before  leaving  the  cubicle  disinfects  his  hands  thoroughly. 
To  diminish  the  risk  of  germs  being  carried  by  the  air, 
partly  directly  and  partly  by  getting  into  the  food  or 
feeding  bottles,  the  room  must  be  well  ventilated.  The 
air  in  it  should  be  often  changed ;  the  walls,  ceilings 
and  floors  should  be  such  as  can  be  easily  washed  ;  and  the 
dust  may  be  reduced  to  a  minimum  by  having  furniture  of 
glass  and  iron  which  can  be  easily  cleaned,  by  having  no 
corners  in  the  room,  and  by  dusting  with  a  damp  duster. 
These  precautionary  measures  are  not  purposeless  and 
excessive.     The  great  value  of  such  precautions  has  been 

441 


THE  PEEVENTION  OF  DISEASE 

proved  by  tlie  results  obtained  in  newly  erected  institutions 
whicL.  were  planned  and  built  and  fitted  up  in  accordance 
with,  the  views  above  expressed. 

As  already  stated,  this  chapter  is  devoted  to  diseases 
which  mostly  affect  children  in  the  suckling  period,  and  I 
jDass  on  therefore  to  speak  of  preventive  treatment  in  con- 
genital syphilis.  Syphilitic  infection  may  be  acquired  by 
the  infant  in  various  ways,  namely  from  a  syphilitic 
wet  nurse,  from  utensils,  feeding  bottles  and  sponges 
used  for  other  children  who  are  syphilitic,  from  sleeping 
with  a  syphilitic  person,  and  from  kissing  by  one  whose 
mouth  is  affected  with  the  disease.  Such  cases  belong  to 
the  group  of  acquired  syphilis,  and  begin  with  the  typical 
initial  lesion  and  show  no  special  modification  in  their 
course  at  the  various  periods  of  life.  Preventive  treatment 
consists  of  the  ordinary  measures  for  the  prevention  of 
syphilis.  "We  can  leave  therefore  the  subject  of  acquired 
syphilis  and  pass  on  to  congenital  syphilis,  which  affects 
the  infant  in  utero,  whether  it  be  inherited  from  the 
father,  from  the  mother,  or  from  both  parents,  and  consider 
whether  it  is  possible  by  treatment  to  prevent  inherited 
syphilis,  or  to  prevent  an  outbreak  of  syphilitic  symptoms 
in  a  child  born  apparently  healthy.  Here,  as  I  pointed  out 
in  the  introductory  remarks,  factors  are  concerned  which 
do  not  fall  within  the  sphere  of  the  physician's  influence. 
"We  are  in  a  position  to  state  what  has  been  amply  verified 
by  the  investigations  of  inquirers  into  this  special  subject, 
namely  that  syphilis  can  by  long  and  energetic  treatment 
be  cured  so  completely  as  to  leave  scarcely  any  risk  of 
infection  possible  for  mother  or  offspring.  But  it  is  seldom 
possible  to  induce  the  man  to  submit  to  this  prolonged 
treatment  before  he  marries.  Often  he  conceals  the  fact 
that  he  is  diseased,  barely  waits  even  till  the  manifest 
symptoms  have  disappeared,  and  then,  without  any  precau- 
tionary measures,  by  sexual  connexion  seriously  injures  a 
young  life  entrusted  to  his  care,  and  of  an  entire  generation 
some  are  destroyed  and  some  are  brought  into  the  world 
heavily  handicapped.  When,  as  is  unfortunately  often  the 
case,  it  is  not  possible  to  cure  syphilis  in  the  husband  by  a 

442 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

long  and  energetic  treatment,  we  must  at  least  endeavour 
to  mitigate  its  effect  upon  mother  and  child  by  suitable 
measures.  There  are,  as  is  well  known,  several  possibilities  : 
the  ovum  may  be  infected  from  the  paternal  side,  and 
abortion,  premature  delivery,  or  still  birth  may  be  the 
result,  or  the  child  may  be  born  with  syphilitic  symptoms, 
or  the  symptoms  may  develop  in  the  course  of  a  few 
weeks  ;  but  the  mother  may  be  free  from  syphilis  and  may 
remain  free,  having  been  made  immune  by  the  foetus, 
according  to  Colles'  law.  In  other  cases  the  mother 
becomes  infected  by  the  father  who  has  recently  become 
syphilitic,  later  she  becomes  pregnant,  and  the  pregnancy 
ends  in  one  of  the  ways  just  enumerated.  And  lastly,  the 
mother  may  become  infected  after  conception  has  occurred, 
and  the  ovum  which  was  healthy  may  subsequently 
become  infected  with  syphilis.  Further,  it  is  important 
in  preventive  treatment  that  we  should  know  whether  in 
any  particular  case  the  woman  is  a  primipara  or  a  multi- 
para. Unfortunately  it  is  generally  the  rule  that  our 
attention  is  first  directed  to  the  matter  by  a  history  of 
premature  or  of  still  births,  and  further  inquiry  is  then 
made.  I  will  now  briefly  refer  to  these  various  cases  and 
merely  state  the  treatment  to  be  adopted. 

In  cases  where  the  husband  has  recently  become  infected 
with  syphilis  the  wife,  if  pregnant,  and  the  husband  should 
both  be  submitted  to  energetic  antisyphilitic  treatment.  I 
advise  this  in  all  cases,  even  when  the  wife  is  free  from 
any  syphilitic  symptoms,  and  it  is  the  more  necessary 
when  she  shows  syphilitic  symptoms.  It  is  evident 
that  the  wife  should  also  be  treated  when  after 
conception  she  has  become  syphilitic.  In  cases  where 
many  miscarriages  and  the  death  of  children  make  us 
suspect  syphilis,  we  should  look  for  signs  of  syphilis  with 
tact  and  caution,  and  should  begin  energetic  antisyphilitic 
treatment  of  both  parents,  even  though  all  signs  and 
symptoms  of  syphilis  are  absent.  The  good  results  of 
this  will  be  obvious  in  the  children  subsequently  born. 
Antisyphilitic  treatment  when  carefully  carried  out  may 
be  looked  upon  as  almost  free  from  any  possible  ill  effect, 

443 


THE  PREVENTION  OF  DISEASE 

and  should  be  used  wittiout  hesitation  in  these  cases,  seeing 
the  good  results  which  follow  its  use. 

Another  question  in  the  preventive  treatment  of  syphilis 
is  whether  a  child  born  of  syphilitic  parents,  and  which  is 
apparently  quite  healthy,  should  be  at  once  treated  with 
mercury,  or  not  till  symptoms  of  syphilis  become  manifest. 
Here  too  we  must  distinguish  between  several  possibilities  : 
if  the  child  is  born  free  from  syphilis,  and  the  father  has 
had  syphilis  but  the  mother  has  shown  no  symptoms  of 
syphilis  during  the  pregnancy,  we  can  postpone  treatment 
of  the  child  because  it  does  not  follow  that  such  children 
will  be  syphilitic.  The  same  holds  good  when  the  mother 
has  previously  shown  signs  of  syphilis  but  has  remained 
quite  free  from  them  during  this  particular  pregnancy  :  the 
child  often  escapes  infection  in  such  cases.  On  the  other 
hand  we  must  not  postpone  preventive  antisyphilitic  treat- 
ment when  the  mother  has  shown  fresh  signs  of  syphilis 
during  this  particular  pregnancy,  or  when  she  has  become 
primarily  infected  with  syphilis  during  the  pregnancy. 

As  to  the  feeding  of  a  child  which  has  or  is  suspected  of 
having  congenital  syphilis — we  must,  considering  the 
serious  disease  which  is  present  or  may  appear,  endeavour 
to  secure  the  most  favourable  conditions  possible ;  breast- 
feeding should  therefore  be  advised  whenever  possible. 
It  is  obvious  that  the  infant  may  only  have  the  breast  of 
its  own  mother,  and  I  consider  it  to  be  unjustifiable  to  ask 
a  wet  nurse  to  undertake  such  a  case,  even  when  she  fully 
understands  the  circumstances  and  is  highly  remune- 
rated. The  want  of  intelligence  in  such  people  does  not 
enable  them  to  estimate  correctly  the  extent  of  the  risk 
which  they  run,  and  apart  from  this  fact,  the  physician 
cannot  conscientiously  make  use  of  the  favourable  pecuniary 
circumstances  of  a  family  in  this  immoral  way — in  short, 
I  feel  I  cannot  take  up  too  decided  an  attitude  against  such 
a  proceeding.  When  physical  exhaustion  or  marked 
anaemia,  deficiency  of  milk,  or  severe  syphilitic  lesions  pre- 
vent the  mother  from  nursing  her  child,  we  must  resort  to 
artificial  feeding,  regardless  of  the  fact  that  this  is  not  a 
favourable  course  for  a  child  with  hereditary  syphilis.     An 

444 


THE  PREVENTION  OF  THE  DISEASES  OE  CHILDREN 

occasional  exception  to  Oolles'  law  has  here  and  there  been 
known,  and  the  mother  does  therefore  run  a  slight  risk 
by  suckling  her  syphilitic  child  and  may  contract  a  primary 
hard  sore.  But  such  exceptions  are  very  rare,  and  no  weight 
should  be  attached  to  this  slight  risk  which  a  mother  may 
be  expected  to  run  for  her  own  child. 

An  infant  suffering  from  congenital  syphilis  is  as  dan- 
gerous to  its  entourage  as  is  anyone  who  is  suffering  from 
acquired  syphilis,  and  similar  precautions  must  be  taken 
against  the  spread  of  the  disease ;  and  I  have  nothing  to 
add  to  this  statement.  Cases  have  occurred  in  which  a 
syphilitic  child  is  breast-fed  by  a  healthy  wet  nurse,  when 
syphilis  was  not  known  or  was  not  suspected  to  exist  till 
syphilitic  symptoms  made  their  appearance  a  few  weeks 
after  birth.  Such  cases  are  not  rare,  and  I  consider  that 
the  only  proper  course  to  adopt  is  at  once  to  remove  the 
child  from  the  breast,  to  put  the  wet  nurse  under  careful 
observation  for  at  least  six  weeks,  and  to  treat  her  by 
inunction  at  the  very  first  appearance  of  symptoms.  If  the 
nurse  declines  to  submit  to  this  quarantine,  it  is  the  dut}^ 
of  the  physician  to  explain  what  may  be  the  possible  result. 

In  concluding  this  subject  I  will  add  a  few  words  about 
syphilis  acquired  during  the  suckling  period.  Infection 
takes  place  generally  by  feeding  either  from  a  wet  nurse 
who  was  not  thoroughly  examined,  or  from  the  use  of  a 
teat  or  spoon  previously  used  by  a  syphilitic  child,  or  from 
the  mother  infecting  the  milk  or  the  cup  by  tasting  the 
milk  when  suffering  from  some  syphilitic  lesions  of  the 
mouth.  The  prevention  of  such  infection  is  by  a  care- 
ful physical  examination  of  the  nurse,  careful  inquiry 
into  her  previous  health  and  history,  and  whenever  possible 
an  inspection  of  her  child ;  we  should  never  rely  upon  the 
medical  certificate  brought  from  a  registry  office,  but  should 
examine  the  nurse,  because  only  then  can  we  assume  the 
responsibility.  The  authorities  have  also  an  important 
duty  to  perform,  and  this  occupation  of  going  out  to  nurse 
should  be  strictly  watched,  because  evils  frequently  arise 
out  of  it,  and  any  breach  of  the  law  should  be  severely 
punished.     How   to   prevent  infection  by  the  other  ways 

445 


THE  PREVENTION   OF  DISEASE 

just  mentioned  is  obvious :  I  need  only  say  tliat  tasting 
the  milk  should  be  forbidden,  for  the  tem^Derature  of  tlie 
milk  can  be  estimated  in  other  ways,  and  there  is  also 
the  possibility  that  other  infective  processes  may  be  con- 
veyed by  tasting  the  milk.  The  risk  of  infection  by  spoon, 
sponge  and  washing  apparatus  has  already  been  mentioned : 
in  this  respect  a  child  suffering  from  syphilis  must  be 
treated  exactly  as  one  would  treat  a  child  suffering  from  a 
contagious  disease.  Infection  by  the  genitals  need  scarcely 
be  taken  into  consideration  at  that  tender  age,  but  sleeping 
in  the  bed  with  an  affected  person  should  be  forbidden  ;  this 
bad  habit  is  not  uncommon  among  the  lower  classes. 
Lastly,  it  should  be  remembered  that  infection  is  convej^-ed 
by  kissing,  and  I  must  not  let  this  op23ortunity  pass  without 
uttering  my  emphatic  protest  against  this  widespread  bad 
habit.  The  physician  should  advise  the  parents  to  refuse 
politely  but  emphatically  to  allow  the  infant  to  be  kissed 
when  it  is  brought  out  to  be  shown. 

A  second  chronic  infective  disease,  which  may  be  acquired 
through  the  placenta  but  more  frequently  ap]3ears  during 
the  early  weeks  of  life,  is  tuberculosis,  and  I  will  devote  a 
few  lines  to  the  preventive  treatment  of  this  during  inf ancj^ 
The  contention  long  waged  as  to  the  possibility  of  the 
direct  conve^^'ance  of  Koch's  bacillus  from  the  maternal  to 
the  foetal  circulation  has  now  been  definitely  settled  by  a 
number  of  observations ;  nevertheless  such  transmission  is 
extremely  rare,  and  we  are  powerless  to  do  anything  by 
treatment  to  prevent  it.  It  is  different  in  the  case  of 
tubercidosis  acquired  after  birth,  and  much  can  be  done 
even  at  that  tender  age  to  lessen  the  dangers  of  infection, 
by  the  modern  methods  of  isolation  and  the  reception  of 
phthisical  patients  into  special  institutions,  and  other 
similar  preventive  measures.  The  pendulum  seems  to  me 
to  be  swinging  too  far  again  in  one  direction,  as  happened 
before,  when  the  communication  of  the  discovery  of  the 
exciting  cause  of  tuberculosis  was  first  made,  and  the  theorj'' 
as  to  infection,  which  was  formerly  kept  within  reasonable 
limits,  now  occupies  the  field,  while  the  well  founded  teach- 
ing about  a  tubercular  disjDOsition,  proved  to  be  correct  by 

446 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

innumerable  observations  made  on  tuberculous  families, 
has  passed  altogether  into  the  background.  "We  welcome 
it  as  a  step  in  advance  in  public  and  private  hygiene,  that 
the  laxity  which  formerly  existed  in  connexion  with  the 
disposal  of  tuberculous  products  has  been  removed,  as  a 
result  of  the  very  useful  researches  of  Cornet  and  Fliigge, 
which  showed  that  prevailing  ideas  were  in  part  erroneous; 
but  it  must  be  pointed  out  that  we  are  apt  to  expect  too 
much  from  these  precautionary  measures. 

A  bodily  condition  which  affords  a  favourable  soil  for  the 
bacillus  plaj^s  at  least  as  important  a  role  in  the  genesis  of 
tuberculosis  as  does  the  exciting  cause  itself,  and  under 
certain  circumstances  an  individual  thus  predisposed  will 
develop  tuberculosis,  while  for  others  who  are  not  thus 
predisposed  there  exists  not  the  least  danger.  The  fight 
against  tuberculosis  is  not  only  to  be  waged  against  the 
infection,  but  also  against  the  tuberculous  disposition,  and 
to  ensure  success  must  include  hygienic  rules  for  the  bring- 
ing up  of  children  and  for  diet. 

An  infant  generally  acquires  tuberculosis  in  one  of  two 
ways,  by  the  digestive  or  by  the  respiratory  tract,  and  may 
suffer  from  gastro-intestinal  or  pulmonary  tuberculosis. 
The  former  can  only  arise  from  artificial  feeding,  at  least  I 
know  of  no  authentic  case  where  tuberculosis  was  acquired 
through  the  milk  of  the  mother  or  of  a  wet  nurse.  Dia- 
gnostic tests  with  tuberculin,  now  regularly  carried  out, 
have  convinced  us  that  there  is  much  bovine  tuberculosis 
among  milch  cows,  and  there  are  many  examples  of  the 
conveyance  of  tuberculosis  in  this  way.  To  prevent  infec- 
tion, the  milk  given  to  the  child  should  come  from  cows 
which  have  been  proved  by  the  tuberculin  test  to  be  free 
from  bovine  tuberculosis  ;  the  milk  should  be  boiled  and 
never  used  either  unboiled  or  heated  below  boiling  point. 
Infection  through  the  respiratory  tract  is  derived  from 
pulmonary  phthisis  in  the  mother  or  father  or  in  both. 
When  speaking  about  suckling  tuberculosis  in  the  mother 
was  named  among  the  contra-indications,  and  I  must 
emphasize  this  again  here.  If  circumstances  permit  a  wet 
nurse  should  be  procured,  because  the  many  digestive  dis- 

447 


THE  PREVENTION  OF  DISEASE 

turbances  produced  "by  artificial  feeding  pave  the  way  in 
snch  cliildren  for  the  development  of  tuberculosis.  The 
child  is  infected  directl}^  by  the  act  of  coughing  when 
moist  particles  containing  bacilli  get  into  the  nose  or  mouth 
of  the  child,  or  it  may  be  infected  by  germs  carried  to  it  in 
the  act  of  kissing,  or  during  some  of  the  many  attentions 
which  are  bestowed  upon  it.  Finally  bacilli  which  get 
into  the  dust  of  the  room  from  dried  sputum  may  infect 
the  child.  Preventive  measures  should  be  directed  against 
all  these  sources  of  infection.  Parents  should  be  advised 
to  do  as  little  as  possible  themselves  for  the  child,  and 
should  allow  others  to  attend  to  it ;  their  sputum  should  be 
received  into  a  cloth  which  is  put  at  once  into  corrosive 
sublimate  solution  and  then  thoroughly  washed  in  a  separate 
vessel.  In  this  way  we  can  best  prevent  infection  by  small 
moist  particles  or  by  dried  sputum. 

Frequent  washing  of  the  hands,  no  kissing,  no  tasting  of 
the  food  or  blowing  it,  are  further  precautions  which  should 
be  observed.  Heubner  has  recently  recommended  the 
establishment  of  special  homes  for  the  children  of  tubercu- 
lous parents :  these  are  very  suitable  for  such  cases ;  the 
child  is  thereby  removed  from  the  source  of  infection,  and 
fresh  air  and  good  feeding  will  tend  to  prevent  the  develop- 
ment of  a  tuberculous  predisposition.  There  is  unfortu- 
nately great  difficulty  in  diagnosing  tuberculosis  in  these 
Yerj  young  children,  and  isolation  of  all  children  who  are 
attacked  is  therefore  not  possible.  At  this  age  tuber- 
culosis generally  assumes  a  form  which  is  unaccompanied 
by  any  external  tuberculous  secretion,  or  at  most  the 
bacilli  are  expelled  with  the  faeces,  and  a  thorough  disin- 
fection of  the  napkins  reduces  the  danger  of  infection  to  a 
minimum  for  the  inmates  of  the  sick  room  or  for  the  persons 
around  the  sick  child. 

The  influence  of  certain  infectious  diseases  upon  the 
incidence  or  manifestation  of  a  hitherto  latent  tuberculosis, 
the  measures  which  may  be  taken  to  prevent  it,  and  the 
preventive  measures  against  scrofula,  which  usually 
appears  only  after   the   lactation   period,    will   be  referred 

to  later. 

448 


THE  PlIEVEXTION  OF  THE  DISEASES  OF  CHILDREN 

From  these  chronic  infectious  diseases  I  pass  to  rickets,  a 
constitutional  malady  which  is  very  common  during  child- 
hood.. The  first  symptoms  often  begin  shortly  after  birth, 
but  more  often  during  the  second  halfyear  of  life,  and 
preveiitive  measures  are  most  effectual  during  this  period. 
So  far  we  have  been  concerned  with  processes  whose  nature 
is  fairly  clear  and  whose  predisposing  and  exciting  causes 
are  largely  known,  but  now  we  are  concerned  with  an  affec- 
tion whose  aetiology  is  still  quite  obscure,  in  spite  of  much 
work  that  has  been  done  in  this  direction.  If  we  have  the 
courage  frankly  to  admit  the  fact  and  not  confine  ourselves 
to  mere  assumptions,  or  believe  that  we  have  reached  the 
bottom  of  the  matter  when  we  have  only  considered  this  or 
that  factor,  then  it  will  be  acknowledged  that  the  prevention 
of  rickets  is  one  of  the  most  difficult  problems  that  confront  us. 
Different  authorities  have  variously  ascribed  the  primary 
cause  of  rickets  to  improper  feeding,  to  unsuitable  homes, 
or  to  some  infectious  condition,  but  a  very  large  experience 
has  convinced  me  that  these  factors  influence  to  some  extent 
the  severity  of  the  disease  and  the  rachitic  manifestations, 
but  are  not  the  cause  of  the  disease  itself.  Many  newborn 
infants  show  unmistakable  signs  of  rickets,  such  as  general 
enlargement  of  the  ends  of  the  costal  cartilages,  defects  in 
the  ossification  of  the  bones  of  the  skull,  curved  tibiae  and 
a  protuberant  abdomen.  This  would  seem  to  be  against 
the  influence  of  the  above-named  factors  and  suggests  some 
hereditary  cause,  particularly  as  the  parents,  more  especially 
the  mothers,  of  such  children  show  signs  of  former  rickets. 
Rickets  is  almost  unknown  in  some  countries  where  infants 
are  badly  fed  and  are  in  unsuitable  homes,  while  in  neigh- 
bouring districts  where  the  social  and  material  conditions 
are  far  better  for  the  infant  rickets  is  very  common.  I  may 
instance  North  Italy  with  its  special  hospitals  for  rickets, 
and  South  Italy  where  rickets  is  scarcely  known.  These 
facts  do  not  support  the  theory  that  it  is  due  to  diet  or  to 
insanitary  surroundings.  In  Germany  some  90  to  95  per 
cent,  of  the  children  suffer  from  rickets  at  some  time  or 
other  of  their  lives,  and  the  disease  is  met  with  in  breast-fed 
children  as  well  as  in  artificially  fed  children,  in  the  palatial 

449  GG 


The  PREVE^^noN  of  disease 

homes  of  the  rich  as  well  as  in  the  hovels  of  the  poor.  I 
confess  that  amid  favourable  conditions  of  life  the  percent- 
age of  cases  is  lower  and  rickets  occurs  in  a  less  severe  form, 
but  experience  has  also  convinced  me  that  in  spite  of  the 
greatest  care  in  diet,  and  in  spite  of  living  in  fresh  air, 
symptoms  of  rickets  have  appeared,  generally  at  the 
beginning  of  the  second  halfyear  of  life.  Personally 
therefore  I  am  of  opinion  that  the  above-named  factors 
affect  the  severity  of  the  disease  but  are  not  its  cause. 
Some  time  ago  I  ventured  to  suggest  the  opinion  that 
rickets  is  a  racial  disease.  I  was  not  able  to  offer  evidence 
in  proof  of  this  view,  and  in  Bohemia,  where  two  races  of 
people  live  side  by  side,  both  suffer  froru  rickets.  But  I 
made  the  suggestion  as  the  result  of  what  has  been  said 
above  about  the  geographical  distribution  of  rickets  and  the 
inadequate  causes  to  which  rickets  is  ascribed.  I  have 
referred  to  this  matter  here,  that  on  the  one  hand  I  might 
give  reasons  why  I  regard  our  preventive  measures  against 
rickets  as  somewhat  ineffectual,  and  on  the  other  hand  to 
combat  statements  made  as  to  the  sure  results  of  this  or  of 
that  method  of  treatment.  It  is  indeed  evident  that  when 
the  child's  diet  and  other  conditions  of  life  are  improved, 
its  whole  organism  is  fortified  and  rendered  less  liable  to  be 
attacked  by  any  disease,  and  I  would  for  that  reason 
always  advocate  such  general  preventive  treatment,  though 
I  could  not  undertake  to  say  that  such  a  child  fed  at  the 
mother's  breast  is  immune  against  rickets,  because  I  am 
almost  daily  convinced  of  the  contrary. 

Though  little  can  be  done  to  prevent  rickets,  yet  the 
complications  can  be  prevented  by  suitable  treatment.  I 
cannot  refrain  in  this  place  from  speaking  about  phos- 
phorus, especially  of  phosphorated  cod  liver  oil,  which  is 
not  very  highly  valued  at  the  present  time.  Though 
theoretically  its  action  is  doubtful,  and  though  possibly  it 
only  attacks  the  rarefaction  of  the  bones  and  leaves 
untouched  the  essential  rachitic  changes,  yet  its  effect  in  a 
very  large  proportion  of  cases  is  excellent,  indeed  its  effect 
upon  the  severe  nervous  symptoms  of  this  disease  might 
almost   be   termed  magical,  and   I  should  not  like   to   be 

450 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

without  this  drug.  By  giving  phosphorus  we  can  in  a 
comparatively  short  time  prevent  those  complications  which 
are  to  be  feared,  complications  affecting  the  respiratory  and 
digestive  organs,  the  blood-building  structures  and  central 
nervous  system,  and  in  this  respect  phosphorus  is  a  most 
valuable  prophylactic.  To  sum  up  briefly,  I  would  first 
endeavour  to  modify  the  future  attack  of  rickets  by  suitable 
diet  and  mode  of  life,  and  at  the  first  sign  of  rickets  would 
begin  this  phosphorus  treatment,  provided  that  the  drug  is 
well  borne  by  the  infant,  and  this  is  mostly  the  case  in 
infants,  though  not  invariably.  One  word  about  institu- 
tions for  sea  baths  and  brine  baths,  so  many  of  which 
have  been  established  in  recent  years,  and  have  been  said 
to  give  excellent  results.  They  certainly  are  of  some 
value,  because  the  methods  there  carried  out  tend  to  check 
the  progress  of  the  rachitic  process,  and  cause  a  rapid 
consolidation  of  the  osseous  structures,  and  thus  counteract 
the  extensive  curvatures  so  frequently  met  with.  And  in 
this  way  they  are  a  valuable  addition  to  treatment  by 
phosphorus. 

Acute  infective  diseases  will  be  described  in  a  later 
chapter.  They  are  not  common  during  infancy.  The  child 
is  less  often  exposed  to  infection  during  this  period  of  life, 
and  there  are  therefore  no  special  preventive  measures 
against  these  diseases  at  this  age.  It  remains  for  me  to 
consider  a  few  disorders  which  may  possibly  be  prevented  by 
suitable  measures.  Mastitis  in  infants  is  the  most  important 
of  these  :  it  is  often  met  with  during  the  first  weeks  of 
life,  and  deserves  special  notice,  not  only  because  it  is  a 
painful  disorder  which  may  become  the  starting  point  of 
a  general  infection,  but  also  because  it  may  lead  to  partial 
destruction  of  the  mammary  gland,  which  in  girls  is  so 
important  an  organ  later  in  connexion  with  maternal 
functions.  A  firm  stand  should  be  taken  against  the 
custom  of  squeezing  the  infant's  breast :  this  is  a  practice 
which  fails  to  accomplish  its  object  and  remove  the  se- 
cretion ;  on  the  contrary  it  increases  the  secretion  by  the 
mechanical  irritation,  and  at  the  same  time  exposes  the 
infant  to  the  danger  of  infection  by  dirty  hands,  from  the 

451 


THE  PREVENTION   OF  DISEASE 

adjacent  skin,  or  from  secretion  wliich  has  been  squeezed 
out  and  covers  tlie  nipple.  This  infection  -may  give  rise  to 
deep-seated  suppurative  inflammation  of  the  breast  which 
never  occurs  when  the  breasts  have  been  left  untouched, 
covered  only  by  a  dry  or  wet  dressing.  "When  there  is  a 
mammary  abscess  it  is  imjDortant  as  a  prophylactic  measure, 
especially  in  girls,  that  the  abscess  should  be  opened  by  an 
incision  parallel  with  the  mammary  ducts,  that  is  by  an 
incision  radiating  from  the  ni23i3le,  to  avoid  a  transverse 
division  of  the  lactiferous  ducts  which  might  lead  to  the 
formation  of  cysts. 

The  other  infections  which  may  proceed  from  the  skin 
and  its  glands  and  their  prevention  have  already  been 
mentioned.  I  have  still  to  consider  a  few  affections  of  the 
mouth  in  connexion  with  the  digestive  organs.  Psoriasis 
linguae  is  a  very  trivial  affection,  probably  never  giving 
rise  to  serious  disturbances,  and  I  can  dismiss  it  in  a 
few  words.  My  personal  impression  is  that  this  condition 
is  never  met  with  except  in  children  fed  with  the  bottle  or 
using  one  indiarubber  teat  for  a  long  time.  I  have  never 
been  able  to  confirm  the  statement  made  of  a  relation 
between  this  affection  and  tuberculosis.  We  cannot  too 
strongly  condemn  the  use  of  rubber  teats  to  soothe  babies. 
"When  we  remember  that  these  indiarubber  teats  are  gener- 
ally first  moistened  by  the  mother  Avith  her  own  saliva,  and 
then  put  into  the  child's  mouth,  it  is  really  astonishing 
that  affections  of  the  infant's  mouth  are  not  more  common. 
This  harmful  custom  is  one  of  the  most  widespread  in  the 
nurser}^,  and  it  is  comparatively  easy  to  do  away  with. 

Aphthous  stomatitis  is  an  affection  against  which  pre- 
ventive measures  are  most  effectual.  Its  connexion  with 
foot  and  mouth  disease  of  cattle  is  maintained  by  many, 
and  though  not  definitely  established  yet  it  is  advisable 
not  to  use  the  milk  of  cows  affected  with  this  disease, 
and  on  the  other  hand  to  boil  the  milk  thoroughly  and 
thus  destroy  any  germs  of  this  disease  which  may  have 
got  into  the  milk.  Further,  the  infant  affected  with 
aphthous  stomatitis  should  be  isolated,  and  all  articles 
used   by  it   should   be  carefully   disinfected.      Lastly,  the 

452 


THE  PREVENTION  OF  THE  DISEASES  OF  OHILDREN 

.1  Ifpctimi  sliould  he  prompt I3'  ami  energeticalh^  treated  to 
prevent  tlip  injurious  pffects  of  complications,  such  as 
diseases  of  the  e^^es  and  of  the  lungs,  which  are  serious 
and  may  be  prevented. 

The  same  is  true  of  ulcerative  stomatitis,  which  may  be 
a  primary  affection  caused  by  infection  of  the  mouth  with 
the  cocci  of  pus,  and  may  thence  spread  to  the  skin,  or  it 
may  be  a  secondary  affection  conveyed  to  the  mouth  by 
the  infant's  fingers,  from  impetigo  of  the  face  or  of  some 
other  part  of  the  body.  Prompt  measures  should  be  taken 
to  prevent  the  spread  of  such  an  impetiginous  dermatitis. 
An  endeavour  must  be  made  to  prevent  the  infant  from 
scratching  the  eruption  and  infecting  its  fingers.;  and  con- 
versely, v/hen  the  affection  begins  in  the  mouth,  we  must 
prevent  its  extending  to  the  skin  and  must  heal  it  promptly. 

Finally,  in  this  chapter  I  must  mention  certain  manipu- 
lations which  in  nnskilled  hands  and  with  unsuitable 
instruments  may  cause  injury.  I  refer  to  enemata.  It  is 
a  very  bad  custom  which  prompts  the  nurse  to  show  her 
skill  by  giving  at  once  an  enema,  though  there  be  no 
indication  for  it.  Often  she  uses  an  unsuitable  instrument 
or  one  which  is  not  free  from  danger,  and  preventive  treat- 
ment which  covers  the  entire  range  of  the  disease  of  chil- 
dren must  guard  too  against  injuries  which  may  be  thus 
produced.  Ulceration,  haemorrhage,  fissures,  even  intus- 
susception, may  be  produced,  and  it  should  be  a  rule  that 
no  enema  be  given  except  when  prescribed  by  the  doctor, 
and  he  should  superintend  the  giving  of  the  first  enema 
and  should  see  that  the  instrnment  does  not  consist  of  a 
syringe  with  a  hard  nozzle,  but  merely  of  a  tube,  a  tap 
and  a  soft  rubber  catheter,  which  can  inflict  no  injury 
nor  allow  of  any  force  being  used. 

Certain  affections  of  the  respiratory  tract  in  this  period 
of  life  require  special  treatment,  partly  because  of  their 
special  significance  and  partly  that  they  maj^  be  prevented. 
Coryza  is  the  chief  of  these,  quite  a  trivial  affection  in  older 
children  but  serious  in  the  sucking  infant,  for  it  is  a 
hindrance  to  sucking,  as  the  nasal  cavities  are  blocked  and 
breathing  interfered  with,  and  it  may  also  be  the  starting 

463 


THE  PEEVENTION   OE  DISEASE 

point  of  infections  which  j)ass  clown  the  respiratory  tract. 
Infectious  catarrhs  caused  by  mechanical  irritation  of  the 
nose  with  sejDtic  objects  have  already  been  mentioned,  and 
the  method  to  be  adopted  in  cleaning  the  infant's  nose  was 
described.  It  still  remains  for  me  to  refer  to  "  catching 
cold"  and  to  say  a  few  words  about  it.  It  would  be  a 
mistake  to  begin  to  harden  the  body  at  this  period  of  life,  as 
some  would  have  us  do.  The  great  hyperaemia  of  the  skin 
in  the  first  weeks  of  life,  the  inability  to  regulate  the  heat 
formation  and  the  very  small  amount  of  movement  make  the 
infant  very  susceptible  to  all  sudden  changes  of  temperature 
and  often  are  followed  by  violent  and  quite  unexpected 
reaction.  One  natural  result  of  this  is  that  we  protect  the 
infant  very  carefully  from  "taking  cold  "  and  from  unfa- 
vourable conditions  of  the  weather ;  do  not  allow  it  to  be 
carried  out  except  on  fine  and  still  days  when  there  is  no 
wind,  and  do  not  let  it  be  too  long  out  of  doors  ;  do  not 
have  it  covered  over  in  the  summer,  nor  allow  the  tempera- 
ture of  the  room  to  rise  too  high  or  fall  too  low.  The  heat 
of  the  bath  water  is  checked  by  a  thermometer,  and  is  only 
gradually  lowered  during  the  later  months  of  the  period  of 
infancy.  These  precautions  generally  suffi.ce  to  prevent 
colds  with  their  serious  sequelae  in  infants.  If  the  infant 
has  a  cold  very  great  care  and  good  nursing  are  needed  to 
prevent  bronchitis  and  broncho-pneumonia,  which  are  very 
dangerous  conditions  in  the  infant  and  readily  follow  the 
cold.  The  transition  between  the  simple  cold  and  these 
conditions  is  often  hardly  noticeable,  and  the  slightest 
neglect  may  give  rise  to  bronchitis.  We  must  utter  a 
warning  then  against  these  colds,  and  every  cold  must 
be  regarded  as  serious  in  the  first  months  of  life.  The 
infant  should  be  kept  in  the  room  till  the  cold  has  quite 
gone,  and  should  be  most  carefully  shielded  from  taking 
any  fresh  cold  even  indoors. 

"What  has  been  said  about  coryza  applies  still  more  to 
bronchitis,  which  even  in  its  mildest  form,  and  limited  to 
the  larger  bronchial  tubes,  is  a  serious  and  very  trouble- 
some affection  demanding  the  greatest  attention.  Most 
cases  of  broncho-pneumonia  which  seem  to  be  simple  are 

454 


THE  PREVENTION  OF  THE  DISEASES  OE  CHILDREN 

really  tlie  result  of  neglex3ted  catarrli  of  the  air  passages, 
and  might  be  prevented  by  proper  care.  Additional  pre- 
cautions are  required  in  institutions  where  the  disease 
assumes  a  very  infectious  character  from  the  crowding  of 
sick  children  in  badly  ventilated  rooms,  and  where  the 
poison  increases  in  intensity  as  it  passes  from  child  to  child. 
The  isolation  of  such  cases  and  careful  disinfection  are 
required,  the  principles  of  which  have  already  been  given. 
As  a  further  precaution  which  should  not  be  neglected,  an 
infant  suffering  from  coryza  and  bronchitis  should  not  be 
bathed  too  soon,  as  this  is  apt  to  aggravate  the  condition. 
Secondary  pneumonias  and  their  prevention  have  already 
been  mentioned  in  so  far  as  thej  arise  during  infancy. 
True  croupous  pneumonia  is  comparatively^  rare  during 
this  period  of  life,  and  we  can  do  but  little  to  prevent 
it  except  by  the  precautions  which  should  be  taken  in  in- 
stitutions against  any  danger  of  infection,  to  which  refer- 
ence has  already  several  times  been  made. 

In  conclusion  I  must  briefly  mention  preventive  measures 
against  the  ill  effects  of  certain  operations  undertaken  for 
cosmetic  reasons  or  as  religious  rites.  I  mean  the  piercing 
of  the  ears  of  girls  and  the  ritual  circumcision  of  Jews. 
The  vanity  of  the  female  sex  does  not  permit  us  to  do 
away  with  ear  piercing,  but  it  should  at  least  be  done  with 
greater  antiseptic  precautions  than  is  generally  the  case. 
The  needles  used  should  be  thoroughly  disinfected,  for  it  is 
often  very  difficult  to  clean  the  instrument  which  is  used, 
and  the  silk  should  be  boiled  or  soaked  in  an  antiseptic,  so 
that  the  obstinate  eczema,  inflammation  and  even  erysi- 
pelas spreading  from  the  pierced  spot  may  be  of  less  frequent 
occurrence.  Apart  from  the  inconvenience  and  risk  of 
these  complications,  they  may  render  the  operation  of  no 
effect.  It  would  be  wisest  to  postpone  piercing  the  ears  till 
girls  are  older  ;  they  will  then  experience  the  pain  of  this 
operation  undertaken  to  satisfy  their  vanity,  and  it  will 
also  be  possible  to  do  the  operation  more  aseptically. 
Ritual  circumcision  is  a  sad  remnant  of  a  fanaticism  of 
past. ages;  it  was  sanctioned  also  as  a  hygienic  measure  in 
the  tropics  and  amid  the  want  of  cleanliness  of  oriental 

455 


THE  PREVENTION   OF   DISEASE 

peoples;  but  this  necessity  no  longer  exists,  and  one  ought 
to  have  courage  to  do  away  altogether  with  this  barbarous 
and  often  dangerous  operation.  In  the  instruments  em- 
ployed and  in  the  operation  as  it  is  performed  by  the  lay- 
man, no  regard  is  paid  to  the  modern  methods  of  the 
treatment  of  wounds  ;  and  apart  from  this  there  are  other 
dangers  arising  at  this  tender  age  from  a  wound  which  is 
not  covered  by  a  dressing  and  is  exposed  to  the  neighbouring 
secretions.  In  several  cases  I  have  seen  a  fatal  result  from 
haemorrhage  and  from  erysipelas  which  started  from  the 
preputial  wound,  and  the  custom,  which  is  not  common  in 
Grermany,  of  sucking  the  wound  and  sprinkling  it  with 
wine  held  in  the  mouth,  may  introduce  into  the  infant's 
body  septic  germs  and  even  the  germs  of  syphilis  and  of 
tuberculosis,  as  has  been  recorded  in  literature.  The  be- 
lief that  this  operation  is  a  preventive  measure  against 
phimosis  and  balanitis,  and  also  later  against  venereal 
infection,  cannot  be  seriously  entertained.  The  number  of 
cases  of  these  diseases  is  always  relatively  small,  and  thej 
are  very  amenable  to  careful  treatment  and  aseptic  precau- 
tions. Another  objection  is  that  the  results  of  the  opera- 
tion performed  for  ritual  reasons  often  need  subsequent 
surgical  treatment,  and  lastly,  the  numerous  cases  of  genital 
infection  in  Jewish  youths  show  plainly  enough  that  the 
mutilation  has  been  useless  in  protecting  against  venereal 
infection. 

I  now  turn  to — 

PREVENTIVE  TREATMENT  IN  EARLY  CHILDHOOD 

In  the  introductory  remarks  when  I  sketched  the  jDlan 
to  be  followed  in  these  pages,  I  pointed  out  that  other 
causes  play  a  part  in  the  diseases  common  to  this  period  of 
life,  and  as  instances  I  enumerated  the  changed  diet  and 
way  of  life  of  children,  their  greater  independence,  their 
intercourse  with  playmates,  and  their  frequent  contact 
with  the  ground.  Up  to  this  age  preventive  treatment 
was  directed  mainly  against  digestive  troubles  and  all  else 
seemed  to  fall  into  the  background,  but  now  prophylaxis 
has  to  face  a  group  of  maladies  which  we  include  under  the 

45fi 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

lerm  uf  acute  iiil'(-'cii(His  disease,  and  their  prevention  is  an 
important  duty  for  the  physician.  The  rapid  growth  of 
organs  favours  the  reception  of  infective  germs  at  certain 
parts  of  the  body  and  requires  other  preventive  measures. 
Games ;  animal  and  vegetable  parasites  in  the  soil,  in 
certain  kinds  of  food  and  in  drinking  water ;  fruit,  sweets 
and  confectionery  which  are  not  always  quite  wholesome — 
all  these  factors  must  not  be  underrated  and  require  care- 
ful consideration.  During  the  later,  years  of  this  period  of 
childhood  the  child  begins  to  go  to  school,  and  is  exposed 
there  chiefly  to  the  risk  of  catching  contagious  diseases  and 
therefore  special  precautions  have  to  be  taken.  These 
infectious  diseases  are  the  most  serious  and  the  most 
common,  and  I  will  therefore  commence  by  speaking  of 
their  prevention. 

Scarlatina. — The  measures  required  to  be  taken  against 
the  infectious  diseases  to  prevent  their  spread,  are  deter- 
mined by  several  factors.  First,  we  must  be  clear  about 
the  way  in  which  the  infection  is  conveyed,  and  secondly 
about  the  period  during  which  infection  may  be  trans- 
mitted. It  is  most  important  to  determine  the  diagnosis 
as  early  as  possible,  because  experience  has  shown  that 
many  of  these  affections  are  less  infective  in  the  initial 
stages  than  in  their  later  stages.  Further,  it  is  desirable 
that  we  should  be  able  to  recognize  the  specific  organism, 
the  presence  of  which  in  the  dwelling  room  of  the  sick  child 
or  on  the  articles  used  by  the  child  may  help  us  to  ascertain 
the  source  of  infection  and  enable  us  to  judge  when  infec- 
tion is  at  an  end.  Unfortunately  some  of  these  postulates 
are  still  impossible,  others  presuppose  a  special  training, 
possessed  indeed  by  the  experienced  physician  but  not  by 
the  parents  under  whose  observation  the  children  generally 
are  at  the  commencement  of  the  illness.  Insufficient 
medical  supervision  of  schools,  on  the  other  hand,  often 
makes  it  possible  for  a  child  to  continue  to  associate  with 
the  other  children  of  that  school,  though  already  suffering 
for  one  or  more  days  from  well  marked  premonitory^  signs 
of  an  infective  disease.  The  want  of  sufficient  strictness  in 
seeing   that   such  infectious  diseases  are  at  once  notified, 

457 


THE  PEEVENTION  OF  DISEASE 

and  tlie  endeavours  made  to  elude  this  notification  by  certain 
classes  of  the  population,  lead  to  serious  consequences,  and  I 
will  give  a  few  examples  of  everj^day  life.  A  milkman, 
regardless  of  the  fact  that  several  of  his  children  are  suffer- 
ing from  an  eruption  with  fever,  continues  to  serve  his 
customers  without  taking  any  precautions ;  he  fills  the 
milk-can  in  his  house,  attends  to  some  small  want  of  his 
sick  children,  and  then,  without  washing  his  hands,  goes  on 
with  his  occupation  as  milkman.  Then,  again,  washer- 
women take  in  washing  which  they  wash  in  their  infected 
houses,  and,  without  changing  their  clothes,  or  in  any  way 
cleaning  themselves,  go  into  other  houses  to  deliver  the 
washing.  Another  frequent  source  of  infection  is  the 
general  provision  shop,  where,  in  the  room  behind  the  shop, 
children  with  some  infectious  disease  may  be  nursed,  and 
when  the  shop  door  opens,  the  shopkeeper  comes  out  from 
the  sick  room  and,  with  hands  unwashed,  proceeds  to  sell 
bread,  fruit,  or  vegetables  to  the  customer,  I  have  selected 
these  few  examples,  though  in  our  daily  life  there  are  many 
others.  The  knowledge  of  these  is  important,  and  we 
should  not  be  content  with  strict  care  in  the  notification  of 
these  cases,  and  with  the  disinfectant  measures  prescribed 
by  the  law,  but  in  every  case  which  cannot  be  explained, 
and  where  the  child  has  not  come  into  contact  with  other 
children,  we  should  prosecute  the  search  for  the  cause, 
because  only  in  this  way  is  it  possible  to  remove  it.  In 
former  years  children's  hosjDitals  suffered  much  from 
infection  in  the  hospital,  for  children  who  were  taken 
thither  for  some  other  illness  often  sickened  and  developed 
an  acute  exanthem,  or,  if  admitted  for  one  infectious  dis- 
ease, contracted  another.  Now.  however,  rooms  for  doubtful 
cases  are  provided,  a  careful  inspection  of  the  children 
brought  up  to  the  hospital  is  made,  and  the  immediate 
separation  of  those  showing  suspicious  symptoms  is  effected. 
Separate  isolation  pavilions  for  the  various  diseases  here 
under  consideration  have  been  built,  and  the  patients  and 
staff  isolated  from  the  remainder  of  the  institution.  These 
precautions  have  reduced  the  danger  to  a  minimum  and 
have  proved  how  much  can  be  done  by  such  measures.     It 

458 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

is  obviously,  too,  the  duty  of  every  j)liysiciaii  in  private 
practice  to  take  precautions  so  that  he  may  not  be  the 
means  of  conveying  any  infectious  disease  ;  the  order  of  the 
visits  to  his  patients  should  be  suitably  arranged.  Similar 
infectious  cases  should  be  visited  in  succession,  and  infec- 
tious patients  should  generally  be  seen  at  the  end  of  his 
round  ;  his  hands  should  be  thoroughly  disinfected  both 
before  and  after  his  examination  of  each  patient ;  he  should 
put  on  a  linen  overall  which  reaches  down  to  his  boots 
and  is  kept  ready  for  him  in  the  anteroom — or  when  this 
is  impossible,  he  should  take  off  his  coat  and  hang  it  up 
outside  the  sick  room,  and  should  afterwards  change  his 
clothes  before  continuing  his  daily  round- — and,  finally,  he 
should  avoid  touching  the  little  patient  more  than  is 
necessary.  All  these  precautions  can  be  carried  out  very 
easily  and  will  considerably  diminish  the  risk  of  infection 
being  conveyed  by  the  doctor.  Having  mentioned  these 
general  rules,  I  pass  on  to  consider  special  preventive 
measures  against  scarlatina. 

The  diagnosis  of  scarlatina  in  its  initial  stage  is  not 
easy :  generally  the  child  sickens  suddenly  with  high 
fever  and  vomiting,  and  these  symptoms  should  make 
us  suspect  scarlatina  and  keep  the  patient  isolated.  Yet 
there  are  cases  in  which  the  initial  symptoms  are  very 
,slight  and  are  overlooked  by  the  parents,  and  the 
physician  is  only  called  in  when  the  scarlet  fever  is 
already  fully  developed.  And,  lastly,  there  are  cases 
in  which  the  symptoms  are  so  slight  that  the  disease 
is  not  recognized  by  those  around  the  child,  and  the 
child  is  allowed  to  go  out  and  even  to  school.  Let  us 
suppose  a  favourable  case  in  which  medical  help  is  called 
in  at  the  very  earliest  symptoms.  We  should  at  once 
proceed  to  examine  the  throat,  for  this  should  never  be 
omitted  in  a  child,  and  see  whether  a  rash  is  present  and 
the  tonsils  swollen.  If  there  is  a  possibility  of  the  disease 
being  scarlatina,  the  child  should  be  isolated.  My  experi- 
ence proves  that  this  course  will  always  save  the  brothers 
and  sisters  from  becoming  infected  at  the  initial  stage,  and 
careful  antiseptic  precautions  will  protect  them  from  later 

459 


THE   PEEA^ENTION   OF   DISEASE 

careful  antiseplic  precautious  will  protect  them  from  later 
iufectiori.  lu  less  favourable  cases  where  medical  aid  is 
uot  sought  till  the  exauthem  is  develoj)ed,  immediate 
separation  of  the  other  children  from  the  patient  will  often 
prevent  infection  and  should  therefore  at  once  be  carried  out, 
and  when  lack  of  room  in  the  house  does  not  permit  this, 
the  child  should  be  transferred  to  a  fever  hospital.  The 
safest  way  of  all  is  to  remove  the  healthy  children  from  the 
house  and  place  them  with  other  families  where  there  are 
no  children.  "When  this  cannot  well  be  done,  it  is  best  to 
wait  till  the  incubation  ]3eriod  is  over  before  deciding  to 
send  the  brothers  and  sisters  to  another  house,  otherwise 
there  is  the  danger  of  infection  being  carried.  In  a  large 
house  where  it  is  possible  completely  to  cut  off  all  com- 
munication between  the  sick  room  and  the  rest  of  the 
house,  we  may  carr}^  this  isolation  out  at  home,  but  we  must 
always  bear  in  mind  that  it  is  after  all  but  a  half  measure, 
as  all  parents  do  not  230ssess  sufficient  self  control  to  keep 
away  for  weeks  from  their  other  children  who  are  living 
under  the  same  roof ;  yet  this  complete  isolation  of  the 
mother  who  is  nursing  the  sick  child  is  absolutely  essential. 
The  father  m.a,y  possibly  be  allowed  to  go  into  the  sick 
room  if  he  puts  on  an  overall  in  an  anteroom  away  from 
the  other  children,  and  then  before  returning  very  carefully 
cleanses  his  face  and  hands  in  a  separate  room.  I  have 
already  enumerated  the  precautions  to  be  taken  by  the 
phj^sician,  and  it  only  remains  for  me  to  describe  the  pre- 
cautions to  be  observed  with  the  other  children  and  their 
schools.  "When  these  children  remain  in  the  same  house  as 
the  sick  child,  they  should  be  kept  away  from  school  and 
not  allowed  to  return  till  the  illness  is  over  and  the  rooms 
have  been  thoroughly  disinfected.  "When  the  brothers  and 
sisters,  after  a  bath  and  the  disinfection  of  their  clothes  and 
belongings,  have  been  sent  to  another  house,  they  should  be 
kept  away  from  school  for  the  extreme  incubation  limit, 
namely  about  twelve  days :  they  may  afterwards  return  to 
school  provided  they  do  not  in  any  way  come  into  contact 
with  any  of  the  surroundings '  of  the  sick  child,  and  only 
see  their  father  according  to  the  rules  laid  down.  The 
physician  should  see  the  children  before  he  gives  leave  for 

460 


THE  PREVENTION  01^  THE  DISEASES  OF  CHILDREN 

them  to  return  to  school.  Tliose  mild  oases  of  scarlatina 
which  run  their  course  with  scarcely  a  symptom  and  very 
slight  rash  are  very  unfavourable  cases  so  far  as  the  con- 
veyance of  infection  is  concerned,  and  for  several  days  or 
during  the  whole  of  the  illness  the  cliild  gets  about  and 
may  spread  the  infection  over  wide  areas.  We  are  power- 
less to  do  anything  in  such  cases,  especially  among  certain 
classes  of  the  population,  and  the  only  way  in  which  the 
disease  can  be  prevented  from  spreading  in  schools  through 
such  cases  would  be  to  appoint  physicians  to  the  schools. 
This  important  prophylactic  measure  has  already  been  too 
long  delayed  to  the  injury  of  the  children. 

Lastly  I  must  mention  forms  of  scarlatina  known  as 
scarlatina  without  eruption,  which  are  not  uncommon  and 
which  present  great  difhculties  in  diagnosis.  It  is  gener- 
ally mistaken  for  diphtheria  which  also  requires  isolation 
and  disinfection,  and,  as  the  course  of  these  cases  is 
generally  severe,  the  danger  of  spreading  infection  in  itself 
is  not  great  in  these  abortive  cases.  Still  it  is  important  to 
arrive  at  a  correct  diagnosis  and  this  can  usually  be  done 
by  the  aid  of  bacteriological  examination.  I  should  like 
also  here  to  j^i'otest  against  the  proposal  made  by  some 
physicians,  that  when  a  child  has  a  mild  attack  of  scarla- 
tina its  brothers  and  sisters  should  be  allowed  to  be  with 
the  sick  child  that  they  may  also  have  a  mild  attack  and 
thus  become  immune  against  scarlatina.  Every  experi- 
enced observer  is  aware  of  the  uncertainty  of  this  insidious 
disease  and  knows  that  the  severest  forms  may  be  conveyed 
by  a  slight  case  of  the  disease;  and,  further,  that  one  attack 
does  not  necessarily  protect  against  a  second.  There  is 
therefore  no  justification  for  such  a  procedure. 

The  germ  of  scarlatina  is  unfortunately  still  unknown, 
and  this  is  to  be  regretted  when  we  have  to  decide  upon 
the  measures  which  are  effectual  for  disinfection  after 
scarlatina  and  the  period  necessary  for  isolation.  We 
know  however  that  the  sloughing  of  the  throat  which  so 
often  accompanies  scarlatina  is  the  effect  of  secondary 
infection  by  ver^^  virulent  streptococci,  and,  further,  that 
these   play   an   important    role    in   causing   complications. 

4G1 


THE   PREVENTION  OF    DISEASE 

The  question  arises,  how  long  is  it  jDOSsible  for  the  iufection 
to  be  conveyed  by  the  patient,  and  how  long  by  a  third 
person  or  by  articles  which  have  been  nsed  by  the  patient  ? 
There  is  no  donbt  that  scarlatina  is  most  infectious  in  the 
eruptive  stage  and  while  the  throat  and  nose  are  the  seat  of 
special  inflammation,  and  that  the  degree  of  contagiousness 
diminishes  towards  the  desquamation  period.  The  state- 
ment made  in  book  after  book  that  the  disease  is  spread  by 
letters  sent  by  the  scarlatina  patient  and  infected  by  the 
scales  shed  by  the  skin  requires  proof.  My  impression  is 
that  the  contagion  of  scarlatina  is  a  fugitive  one,  and 
begins  to  disappear  directly  the  skin  peels  and  the 
epidermis  begins  to  be  regenerated,  and  that  it  is  then  to  a 
great  extent  harmless.  Nevertheless  one  would  not  dis- 
infect the  room  used  by  the  patient  until  all  scales  have 
been  completely  removed  from  the  skin  by  frequent  and 
prolonged  baths  and  soap  and  water,  and  as  we  cannot 
begin  to  bathe  even  an  uncomplicated  case  before  the  fourth 
week,  the  disinfection  will  have  to  be  postponed  to  about 
the  beginning  of  the  fifth  week.  The  traditional  rest  in 
bed  for  six  weeks  is  unnecessary  when  the  course  of  the 
disease  is  normal,  and  I  shall  I  think  meet  with  no  oppo- 
sition today  when  I  plead  for  thorough  ventilation  of  the 
sick  room,  a  frequent  change  of  body  linen  and  bed  linen, 
which  after  being  used  should  be  put  into  a  solution  of 
corrosive  sublimate  for  twelve  to  twenty-four  hours  and 
should  afterwards  be  separately  washed.  The  hands  and 
face  of  the  child  should  be  washed  at  least  once  daily  with 
warm  soap  and  water.  Great  importance  must  be  attached 
to  the  care  of  the  mouth,  not  only  because  many  of  the 
secondary  infections  which  may  proceed  from  the  mouth 
can  thus  be  considerably  limited,  but  also  because  we  can 
reduce  the  contagiousness  by  washing  away  the  secretion 
poured  out  by  the  mucous  membrane  of  the  throat  and 
nose.  In  every  case  in  which  there  is  any  sore  throat, 
we  should  wash  out  the  mouth  several  times  a  day  ac- 
cording to  the  severity  of  the  affection,  using  plenty  of 
lukewarm  boiled  water  or  a  mild    antiseptic  and  passing 

462 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

part  of  tlie  fluid  through  the  nose  to  remove  any  secretion 
which  is  there.  Personally  I  attach  little  value  to  injec- 
tions of  carbolic  acid  into  the  tonsils  ;  it  is  very  difficult  to 
do  when  the  doctor  is  alone  or  has  only  the  help  of  the 
mother,  and  moreover  children  are  so  very  susceptible  to 
carbolic  acid  that  I  prefer  to  avoid  its  use.  I  attach 
much  more  importance  to  well  rubbing  the  skin  during  the 
entire  course  of  the  disease  and  especially  during  the 
desquamation  period  with  fat,  using  some  pure  form  of 
fat  which  will  not  undergo  decomposition  :  in  this  way  we 
can  best  prevent  the  flakes  of  peeling  skin  being  scattered 
in  the  form  of  dust.  When  the  time  has  arrived  for  the 
disinfection  of  the  rooms,  one  room  should  be  first  dis- 
infected and  prepared  to  receive  the  convalescent  patient 
and  his  new  or  thoroughly  cleansed  clothes.  The  bedding 
must  be  exposed  to  the  action  of  steam,  and  in  every  large 
town  there  are  special  places  where  this  is  done  ;  carpets 
and  curtains  which  were  in  the  sick  room  should  be  cleaned 
by  the  same  process ;  the  floor  and  walls  should  be  washed, 
and  for  this  purpose  I  use  a  solution  of  corrosive  sublimate 
of  one  in  1,000.  Toys,  picture  books,  vessels  for  eating  and 
drinking  which  have  been  used  by  the  patient  should  be 
destroyed  ;  cupboards  should  be  opened  wide,  their  contents 
spread  out  in  the  room,  and  all  be  then  exposed  for  twenty- 
four  hours  to  the  vapour  of  formaldehyde.  Since  Schloss- 
mann and  Flligge  have  both  stated  that  formaldehyde  at 
a  dry  heat  becomes  altered,  I  have  now  for  about  eighteen 
months  used  steam  at  the  same  time,  which  is  produced  by 
a  kettle  of  water  heated  by  a  spirit  lamp  and  placed 
beside  the  disinfecting  apparatus.  The  rest  of  the  rooms 
should  then  be  disinfected,  the  anteroom  and  the  kitchen, 
and  for  these  a  steaming  for  about  six  hours  suffices. 
When  these  precautions  have  been  taken,  in  no  case  of 
mine  have  any  of  the  brothers  and  sisters  taken  the  infec- 
tion on  their  return  home,  and  it  has  always  fortunately 
been  possible  for  me  by  adopting  the  preventive  measures 
described  above  and  by  isolation  of  the  sick  room  to  limit 
the  disease  to  the  child  attacked. 

I  have  still  to  mention  the  preventive  treatment  of  the 

4G3 


THE   PREVENTION   OF   DISEASE 

complications  which  occiip}'^  au  important  j^lace  in  the  path- 
ology of  scarlatina.  The  frequent  and  thorough  cleansing  of 
the  mouth  and  nose,  as  also  of  the  skin,  has  been  mentioned; 
the  same  careful  treatment  is  necessary  for  the  genital 
organs,  especially  in  girls,  for  they  not  rarely  become  the 
seat  of  catarrhal  processes  and  even  of  noma.  Other 
points  belong  rather  to  the  field  of  therapeutics  proper  and 
do  not  fall  within  the  scope  of  this  work,  and  I  will  there- 
fore add  only  a  few  words  as  to  the  preventive  treatment 
of  the  nephritis.  It  is  too  optimistic  to  believe  that  it  is 
always  possible  to  prevent  nephritis  by  strict  milk  diet 
combined  with  rest  in  bed  ;  the  frequency  of  renal  compli- 
cation depends  very  much  more  upon  the  character  of  any 
given  epidemic  than  upon  what  the  patient  does  after  the 
eruption  has  passed  away,  and  I  have  often  seen  no  nephritis 
develop  in  children  of  the  lower  classes  who  were  sent  out 
into  the  open  air  directly  the  fever  had  ceased  and  who 
were  given  a  mixed  diet,  while  it  developed  in  other  chil- 
dren who  were  kept  in  bed  at  a  uniform  temperature  and 
were  placed  on  a  strict  milk  diet.  I  do  not  mean  that  milk 
diet  and  a  plentiful  supply  of  non-stimulating  liquids  are 
valueless,  for  I  am  convinced  that  even  where  nephritis 
eventually  sujDervenes,  it  runs  a  milder  course  when  this 
prophylactic  regime  is  carried  out  than  when  such  precau- 
tions are  omitted,  but  I  would  not  place  too  great  reliance 
upon  them,  and  often  they  are  very  difficult  to  carry  out  on 
account  of  the  child's  aversion  to  them.  In  severe  cases 
with  threatened  heart  failure,  small  pulse  and  other  serious 
symptoms,  fear  of  an  impending  nephritis  need  not  deter  us 
from  giving  alcohol  and  other  stimulants  temporarily  for 
such  symptoms.  I  have  often  given  alcohol  without  any 
subsequent  injurious  effect  upon  the  kidneys.  It  is  not 
necessary,  I  think,  to  explain  that  special  and  careful 
nursing  and  food  are  required  during  convalescence  from 
scarlatina,  and  that  care  must  be  taken  that  the  patient 
does  not  catch  cold. 

Next  I  pass  to  the  prophylaxis  of  measles.  Its  contagion  is 
also  unknown,  but  from  the  results  of  clinical  experience  we 
can  state  that  it  is  far  more  communicable  than  that  of  scarla- 

4G4 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

tina.  The  contagiousness  of  measles  is  at  its  maximum 
during  the  initial  stage  of  the  catarrh  of  the  mucous  mem- 
branes and  the  development  of  the  rash ;  and  as  it  was  not 
possible  till  recently  to  make  a  certain  diagnosis  at  this 
early  stage,  epidemics  of  measles  generally  spread  widely 
and  rapidly,  so  that  we  seldom  saw  a  child  which  had  not 
taken  the  infection  during  one  or  other  epidemic.  When. 
in  the  families  of  princes,  measures  were  taken  to  seclude 
the  children  and  thus  keep  them  from  all  possibility  of  con- 
tact, they  developed  the  illness  later,  when  the  duties  of 
their  station  in  life  necessitated  their  coming  into  contact 
with  the  people.  During  the  various  epidemics  of  measles 
in  Prague — some  of  them  very  extensive  epidemics  which  I 
had  the  opportunity  of  observing — I  was  not  once  able  to 
prevent  the  brothers  and  sisters  of  the  child  from  contracting 
the  infection  however  early  they  were  isolated,  that  is  at 
the  commencement  of  suspicious  catarrhal  symptoms.  By 
causing  the  healthy  children  to  be  removed  from  the 
infected  house,  I  found  that  I  merely  took  the  disease 
into  another  house,  and  came  finally  to  the  fatalistic  con- 
clusion that  I  must  be  content  with  half  measures,  and 
restrict  myself  to  keeping  the  children  away  from  school, 
and  letting  all  care  be  taken  when  they  went  out  for  walks 
during  the  twelve  or  fourteen  days  of  the  incubation  period, 
but  as  I  said  before  I  did  not  succeed  in  keeping  the  brothers 
and  sisters  free  from  infection.  A  few  years  ago  Koplik, 
an  American,  pointed  out  a  tolerably  certain  prodromal 
sign  of  measles,  namely  the  appearance  of  spots,  which  have 
been  named  after  him,  upon  the  mucous  membrane  of  the 
cheek  and  gums  some  five  or  six  days  before  the  eruption 
of  the  exanthem  and  before  the  beginning  of  the  catarrhal 
symptoms,  and  it  may  thus  be  possible  for  us  to  isolate  such 
cases  early  enough,  that  is  before  there  is  any  risk  of  infection, 
and  in  this  way  we  may  check  the  spread  of  this  disease. 
Since  hearing  of  Koplik's  observations  I  have  only  seen  one 
slight  epidemic  of  measles,  and  I  can  state  that  I  was  able 
in  a  few  cases  to  isolate  the  patient  early  enough,  and  so 
prevented  the  infection  from  spreading  to  the  brothers  and 
sisters.     I  attach  less  value  to  the  prodromal  sign  given  by 

465  HH 


THE   PEEVENTION  OP  DISEASE 

Meimier,  wlio  states  that  tliere  is  a  distinct  loss  in  weight 
during  the  incubation  stage  in  children  about  a  week  before 
the  eruption  appears,  although  the  child  seems  otherwise 
well.  Apart  from  the  fact  that  it  is  not  always  easy  in  private 
practice  to  obtain  this  information,  though  it  can  be  done  in 
hospitals,  such  variations  in  weight  in  children  may  be  due 
to  other  causes  and  are  so  inconstant  that  but  little  value  can 
be  attached  to  them.  Koplik's  sign,  on  the  other  hand,  almost 
constantly  appears  in  measles  ;  it  is  absent  in  other  infectious 
diseases,  can  be  readily  observed  at  once  even  by  one  who 
is  not  very  experienced,  and  the  diagnosis  can  be  made  by 
simple  inspection  of  the  mouth.  I  ought  to  state  that  so  far 
as  my  experience  of  this  sign  has  gone,  and  it  is  not  yet  an 
extensive  experience,  there  seems  to  be  some  prognostic 
value  in  this  sign,  and  that  the  severity  of  the  disease  bears 
a  direct  relation  to  the  number  of  spots  in  the  mouth. 

Measles  is  most  infectious  during  the  stage  of  the  com- 
mencing catarrh  and  the  rash,  but  it  very  quickly  loses  its 
contagiousness,  and  in  uncomplicated  cases  danger  of  infec- 
tion is  over  in  a  few  days.  The  contagion  is  not  so  readily 
conveyed  by  a  third  person  as  it  is  in  other  contagious  dis- 
eases, and  I  do  not  believe  that  the  infection  is  carried  in 
letters,  nor  do  I  consider  that  the  toj^s  of  the  child  are  any 
serious  source  of  infection.  In  most  cases  infection  is 
through  direct  contact  with  a  patient  suffering  from 
catarrh,  apparently  a  bad  cold  with  some  catarrh  of  the 
eyes,  and  only  as  the  epidemic  begins  to  appear  do  we 
recognize  the  nature  of  the  case.  From  what  has  been 
said,  it  would  seem  unnecessary  to  be  so  strict  in  the  disin- 
fection of  the  house  as  after  scarlatina.  It  is  sufficient  if  the 
bedding  is  disinfected,  the  room  washed  with  corrosive 
sublimate  solution,  the  books  and  toys  thoroughly  cleaned, 
and  the  sick  room  well  aired  ;  the  other  rooms  should  be 
well  cleaned,  and  after  two  or  three  baths  the  child  may  be 
sent  to  school.  The  case  is  otherwise  when  there  has  been 
severe  bronchial  catarrh  giving  rise  for  some  time  to  infec- 
tious secretion,  which  may  cling  to  various  parts  of  the 
room  used  by  the  patient ;  disinfection  should  then  be 
carried  out  in  exactly  the  same  way  as  was  described  for 

466 


THE  PREVENTION  OE  THE  DISEASES  OF  CHILDREN 

scarlatina.  Tlie  same  liolds  good  for  broncho-pneumonia 
complicating  measles  ;  tlie  child  must  be  kept  away  from 
his  companions  of  the  same  age,  and  the  house  will  require 
thorough  disinfection.  Physicians  and  parents  and  all  who 
have  any  intercourse  with  the  sick  child  should  observe  all 
the  precautions  described  above.  Children  who  have 
run  the  risk  of  infection  should  be  kept  away  from  school 
during  the  incubation  period,  and  we  should  take  care 
that  they  do  not  come  into  contact  with  other  children 
when  they  are  out  for  walks  or  at  games.  The  compli- 
cations and  after  effects  of  measles  depend  to  some  ex- 
tent upon  the  character  of  the  affection,  nevertheless 
prophylactic  measures  in  various  directions  are  very  effi- 
cacious. Owing  to  the  strong  tendency  to  affections  of 
the  respiratory  mucous  membranes  cold  must  be  carefully 
guarded  against,  and  good  ventilation  of  the  room  pro- 
vided. An  even  moderate  teraperature,  a  moist  atmo- 
sphere kept  up  by  a  steam  kettle,  frequent  change  of  the 
air  of  the  room  during  which  the  child  should  be  taken 
into  an  adjacent  and  equally  warm  room  or  should  merely 
be  well  covered  up,  according  to  the  season  of  the  year,  are 
the  best  precautions  against  these  complications.  It  is 
important  to  wash  out  the  mouth  and  nose  several  times  a 
day,  and  to  change  the  linen  daily  or  more  often  if  neces- 
sary. Great  caution  is  required  in  deciding  when  the  first 
bath  should  be  given ;  young  children  who  seem  almost 
well  and  have  but  very  little  cough  are  difficult  to  keep 
in  bed,  and  we  are  sometimes  in  rather  too  great  a  hurry  in 
these  cases,  and  bad  results  follow.  I  never  allow  the  child 
to  be  bathed  till  the  cough  has  completely  ceased  for  two  or 
three  days,  and  the  mucous  membrane  of  the  mouth  has 
assumed  its  normal  condition  and  the  skin  shows  but  very 
slight  trace  of  any  pigmentation  left  by  the  rash.  The 
room  must  be  warm  in  which  the  bath  is  to  be  given,  the 
bath  water  not  under  95°  F.,  and  the  child  must  be  put  to 
bed  directly  afterward  for  several  hours  :  it  is  therefore  best 
to  give  it  in  the  evening  before  the  child  goes  to  sleejD.  All 
these  are  small  but  im23ortant  matters,  "We  must  not  be  in 
too  great  a  hurry  in  letting  the  child  go  out  for  the  first 

467 


THE  PREVENTION   OF  DISEASE 

tinie,  especially  wlien  the  season  of  the  year  and  tlie  weather 
are  nnfavonrable.  The  combination  of  measles  with  whoop- 
ing congh  is  rightly  looked  upon  as  grave,  especially  as 
epidemics  of  measles  and  of  whooping  congh  seem  to  stand 
in  some  close  relation  to  one  another,  and  each  of  these  dis- 
eases seems  to  predispose  to  infection  by  the  other.  The 
preventive  measures  will  be  given  under  "  "Whooping  Cough," 
and  I  would  therefore  refer  the  reader  to  this  later  section. 

Lastly,  I  have  to  mention  the  connexion  of  measles  with 
tuberculosis,  which  under  certain  social  conditions  and  with 
hereditary  predisposition  assumes  a  serious  form.  I  need 
only  in  this  place  point  out  how  often  a  hitherto  latent 
tuberculosis  of  the  bronchial  glands  becomes  manifest  under 
the  influence  of  measles,  and  as  a  prophylactic  against  it 
all  children  suspected  of  a  tendency  to  tuberculosis  should 
be  anxiously  guarded  from  infection,  but  it  is  often  very 
difficult  in  practice.  Frequently,  too,  we  see  that  a  patient 
suffering  from  measles  and  living  in  a  phthisical  environ- 
ment develops  tuberculosis  from  patches  of  broncho- 
pneumonia. It  is  exactly  for  these  cases  that  Heubner's 
excellent  idea  is  so  useful,  of  providing  special  homes  for 
children  who  are  predisposed  to  tuberculosis  or  who  are 
exposed  to  the  danger  of  infection  from  tuberculosis,  and 
in  certain  special  cases  we  should  advise  that  this  should  be 
done,  although  in  ordinary  cases  of  measles  we  should  avoid 
sending  the  child  to  a  hospital,  knowing  that  this  does  not 
favourably  influence  the  course  of  measles.  It  is  not  my 
task  to  describe  in  detail  the  preventive  measures  which 
should  be  carried  out  in  the  hospital,  and  I  will  merely  say 
that  the  wards  for  measles  should  be  so  arranged  that  it  is 
possible  to  isolate  patients  suffering  from  pneumonia  or  from 
tuberculosis  in  S23ecial  well  ventilated  rooms,  and  to  avoid 
crowding  patients  together  in  large  and  densely  filled  wards. 

Rubeola  (or  ''  German  measles  ")  is  closely  related  to 
measles  and  is  often  classed  with  measles.  It  differs 
from  measles  in  the  catarrh  being  absent  or  slight — the 
difference  upon  which  most  stress  must  be  laid — and  in 
the  absence  of  Koplik's  spots,  and  observations  of  epidemics 
of  rubeola  justify  us  in  regarding  this  affection  as  a  dis- 

468 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

ease  sui  generis.  Its  contagion  is  unknown,  but  it  appears 
to  be  very  transient  and  it  possesses  its  greatest  power 
of  infection  during  th.e  eruptive  stage.  The  small  amount 
of  secretion  from  the  mucous  membranes  makes  the  period 
during  which  there  is  danger  of  infection  a  very  short 
one  and  the  milder  measures  of  disinfection  described  in 
the  previous  paragraph  suffice  to  prevent  the  spread  of 
German  measles.  In  uncomplicated  cases — and  rubeola 
generally  runs  a  simple  course — the  patient  may  safely  be 
sent  to  school  ten  days  after  the  eruption,  after  he  has  had 
two  or  three  baths.  The  brothers  and  sisters  should  be 
kept  under  observation  till  the  incubation  period  of  twelve 
to  fourteen  days  is  passed.  Conveyance  of  the  disease  by  a 
third  person  or  by  utensils  used  by  the  patient  need  scarcely 
be  considered. 

For  the  prevention  of  smallpox,  we  have  in  Jenner's 
vaccination,  as  the  brilliant  results  in  Grermany  show,  a 
method  which  enables  us  completely  to  stamp  out  this  devas- 
tating and  disfiguring  disease.  It  is  much  to  be  regretted 
that  all  civilized  states  do  not  yet  enforce  compulsory 
vaccination  and  revaccination  of  their  inhabitants,  and  are 
content  often  with  less  strict  compulsory  vaccination.  In 
Austria  a  certificate  of  successful  vaccination  is  required 
when  the  child  goes  to  school,  and  primary  vaccination  or 
revaccination  of  recruits  for  the  army  is  also  compulsory. 
It  is  noticeable  in  these  cases  that  the  instinct  of  the 
people  anticipates  the  care  of  the  government  for  them,  and 
physicians,  at  least  in  the  towns,  meet  seldom  with  any 
opposition  to  vaccination,  but  it  is  rather  welcomed.  We 
owe  it  principally  to  this  fact  that  even  in  Austria  the 
number  of  cases  of  smallpox  steadily  decreases,  and  for 
years  at  a  time  there  may  be  no  smallpox  to  treat.  But  if 
smallpox  is  really  to  be  stamped  out  by  vaccination,  then 
more  stringent  laws  are  necessary,  non-compliance  with 
which  should  be  severely  punished.  Every  child  should  be 
vaccinated  in  the  first  year  of  life,  and  the  vaccination 
should  be  repeated  at  intervals  of  not  more  than  ten  years. 
Great  importance  should  be  attached  to  this  revaccination, 
as  our  military  results  prove  the  protection  against  small- 

469 


THE  PREVENTION  OF  DISEASE 

pox  lasts  only  a  certain  time,  and  primary  vaccination  alone 
is  therefore  only  a  lialf  measure. 

At  tlie  jDresent  time  we  have  not  yet  reached  the  point 
when  we  may  pass  variola  by,  and  we  must  therefore  briefly 
consider  preventive  measures  required  in  the  treatment  of 
smallpox.  Of  the  three  stages  in  the  course  of  a  smallpox 
case — the  eruptive,  the  suppurative  and  the  desquamative 
stage — the  latter  is  by  far  the  most  dangerous  so  far  as  con- 
veyance of  infection  to  others  is  concerned  ;  the  unknown 
organized  virus  shows  great  power  of  resistance,  and  even 
when  dry  in  the  crusts  left  by  the  pustules  is  still  virulent  for 
a  long  period.  The  desquamative  process  often  lasts  for 
several  weeks,  and  as  a  j^reventive  measure  j^atients  should 
not  be  permitted  to  come  in  contact  with  the  outer  world 
till  all  the  spots  are  completely  healed  and  the  crusts  have 
been  completely  destroyed.  To  hasten  the  drying  up  of  the 
vesicles  and  as  far  as  possible  prevent  their  further  exten- 
sion, baths  are  used  with  the  addition  of  some  mild  anti- 
septic. The  attendants  and  the  physician  should  be  revac- 
cinated,  and  before  leaving  the  sick  room,  which  should 
not  be  entered  without  previously  putting  on  a  linen 
overall,  the  hands  and  face  and  even  the  beard  should  be 
thoroughly  washed  with  soap,  and  disinfected  with  alcohol 
and  sublimate,  in  order  to  remove  and  make  innocuous  the 
small  scales  which  may  adhere  to  these  parts.  It  seems  to 
me  to  be  necessary  too  to  take  a  bath  and  to  change  one's 
clothes  before  visiting  other  patients.  Utensils  used  in  the 
sick  room  should  not  be  carried  into  other  rooms,  but  should 
be  washed  in  a  place  specially  set  apart  for  this  purpose. 
We  should  not  omit  disinfection  of  the  patient's  faeces  and 
urine ;  for  the  variolous  process  is  known  to  affect  also  the 
mucous  membranes  of  the  intestinal  and  urogenital  tract, 
and  these  excretions  may  also  be  infectious.  Lime  is  best 
for  this  purpose.  When  the  disease  is  past,  the  whole  house 
must  be  rigorously  disinfected,  all  things  used  by  the 
patient  should  be  destroyed  by  burning  when  possible, 
and  the  remainder,  and  bedding,  carj^ets,  and  curtains, 
must  be  disinfected  by  steam.  The  furniture  should  be 
washed  with  a  solution  of   corrosive  sublimate,  the   floor 

470 


THE  PREVENTION  OF  THE  DISEASES  OE  CHILDREN 

and  walls  slionld  be  likewise  washed  and  afterwards 
repainted  or  repapered ;  special  care  slionld  be  taken  to 
destroy  the  crusts  formed  by  the  pustules,  and  this  is  best 
done  by  bnrning.  Lastly,  the  honse  should  be  disinfected 
by  formaldehyde  with  steam,  or  by  giycoformol  ;  it  should 
then  be  aired  for  several  days,  and  un-revaccinated  inmates 
should  not  be  permitted  to  return  to  the  honse  until  they 
have  all  been  satisfactorily  revaccinated. 

I  have  still  to  mention  the  cases  where  a  pregnant  woman 
is  attacked  with  smallpox,  and  the  measures  required  to  be 
taken.  When  pregnancy  is  iiot  far  advanced  expulsion  of 
the  ovum  generally  occurs,  but  when  pregnancy  has  nearly 
run  its  full  course  there  are  several  possibilities.  The  child 
may  be  born  during  the  incubation  period  of  smallpox,  is 
still  susceptible  to  vaccination  but  sickens  in  spite  of  it  — 
and  I  can  call  to  mind  such  a  case  in  the  Foundling  Hos- 
pital where  vaccination  and  smallpox  pustules  developed 
side  by  side  ;  or  the  child  may  be  born  having  an  eruption 
of  smallpox  pustules  or  remnants  of  them,  and  this  child  is 
naturally  not  susceptible  to  vaccination  ;  or  it  may  in  utero 
have  become  immune  against  smallpox  and  against  vaccin- 
ation without  itself  having  been  ill.  Nevertheless  it  is 
obviously  our  duty  to  vaccinate  these  children  directly 
after  birth,  and  carry  out  all  necessary  precautions  as 
mentioned  above.  Lastly,  it  may  happen  that  the  mother 
sickens  only  towards  the  end  of  gestation,  and  that  the 
child  is  born  during  the  desquamative  stage  or  during  the 
mother's  convalescence  :  in  these  cases  either  the  child  may 
be  immune,  as  is  proved  by  the  fact  that  vaccination  does 
not  take,  or  the  vaccination  takes  and  the  infection  of  the 
newborn  infant  may  be  prevented. 

In  conclusion,  a  few  words  must  be  said  about  vaccina- 
tion, which  has  become  comparatively  easy  since  the  use  of 
human  lymph  has  been  given  up,  and  the  objection  to 
vaccination  raised  by  anti- vaccinators  because  of  its  liability 
to  convey  syphilis  no  longer  holds  good.  The  soundness  of 
the  animals  from  which  the  vaccine  lymph  has  been  obtained 
is  always  tested  by  an  autopsy  on  the  body  of  the  animal, 
made  before  the  lymph  is  sent  out.    In  obtaining  the  lymph 

471 


THE  PREVENTION  OF  DISEASE 

the  vaccinated  surface  is  kept  clean  by  dressings,  by  steri- 
lizing all  instruments  used  for  the  oj)eration,  and  by  otlier 
similar  precautions  ;  and  freedom  from  germs  in  tbe  lympb 
is  secured  by  the  prolonged  action  of  glycerine  :  as  a  re- 
sult there  has  been  a  great  decrease  in  the  number  of  cases 
of  infection  with  microbes,  especially  with  staphylococci. 
Further  rules  are  that  asepsis  should  be  observed  when  vac- 
cinating ;  the  child's  skin  should  be  previously  well  cleaned 
with  soap  and  brush,  ether  or  alcohol.  A  piece  of  cotton 
wool  should  be  interposed  when  blowing  out  the  lymph  from 
the  tube,  the  glass  plate  upon  which  it  is  received  should  be 
disinfected,  and  the  instruments  should  be  boiled.  When 
the  pustule  develops  we  must  cover  it  with  a  suitable  dress- 
ing which  should  not  be  discarded  till  the  wound  has  healed. 

Varicella  is  generally  a  very  trivial  affection  and  the  pre- 
ventive measures  against  it  are  simple.  The  contagion  soon 
loses  its  virulence  and  infection  is  easily  prevented.  When 
the  pustules  have  dried  up,  a  few  baths  with  the  addition  of 
some  mild  antiseptic  and  the  use  of  plenty  of  soap  suffice  to 
render  the  patient  non-infectious.  In  disinfecting  the 
rooms  it  is  sufficient  to  use  the  simplest  measures  above 
mentioned.  The  brothers  and  sisters  should  be  kept  away 
from  school  till  the  incubation  period  is  over,  that  is  for 
about  fourteen  days.  Certain  precautions  should  be  observed 
in  view  of  complications  ;  the  mouth  must  be  kept  very 
clean  to  prevent  infection  spreading  from  the  eruption  on 
the  mucous  membrane,  and  the  urine  should  be  tested  in 
case  nephritis  should  supervene.  These  are  the  principal 
precautions  needed.  We  should  avoid  sending  patients  into 
hospital  because  experience  has  shown  that  varicella  may 
then  run  a  severer  course,  and  gangrene  of  the  pustules  and 
secondary  infections  arising  therefrom  make  the  prognosis 
far  worse.  Lastly,  I  must  not  omit  to  mention  that  we 
ought  to  make  a  correct  diagnosis,  as  much  mischief  may 
be  caused  by  mistaking  a  mild  or  abortive  form  of  smallpox 
for  chickenpox. 

I  proceed  now  to  speak  of  the  preventive  measures  against 
diphtheria.  The  discovery  of  the  exciting  cause  of  diph- 
theria, the  Klebs-Loffier  bacillus,  about  the  specific  action 

472 


THE  PEEVENTION   OF  THE  DISEASES  OF  CHILDREN 

of  wliich  there  can  be  no  doubt,  has  enabled  us  to  demon- 
strate the  existence  of  the  disease,  and  to  devise  sure  pre- 
ventive measures.  The  fact  that  Behring  and  his  pupils 
have  given  us  a  specific  cure  for  diphtheria,  and  the  pos- 
sibility of  obtaining  at  least  a  temporary  protection  against 
diphtheritic  infection  by  using  this  protective  serum,  are 
considerations  which  place  our  modern  preventive  treatment 
of  diphtheria  upon  a  strictly  scientific  basis,  and  when 
rightly  used  it  is  followed  by  very  good  results.  We  know 
the  great  vitality  which  is  possessed  by  the  bacillus  of 
diphtheria  and  we  know  that  it  may  be  spread  not  only 
through  contact  with  the  patient  but  also  through  the  air, 
by  the  most  diverse  objects,  such  as  toys,  imperfectly 
washed  fruit,  and  bread,  through  soiled  hands,  and  through 
the  secretion  of  the  nose  and  throat  of  healthy  persons 
who  are  apparently  immune  against  diphtheria.  We 
must  briefly  then  consider  all  these  possible  sources  of 
infection,  and  adopt  commonsense  preventive  measures 
against  diphtheria  which  embrace  them  all.  During 
epidemics  of  diphtheria  we  should  avoid  getting  articles 
of  food  from  houses  in  which  are  patients  suffering  from 
diphtheria,  and  the  authorities  should  not  allow  the  sale 
of  food,  and  especially  of  milk  and  bread,  by  persons 
whose  children  have  suffered  from  diphtheria  till  after 
the  house  and  shop  have  been  thoroughly  disinfected. 
There  would  be  great  difficulties  in  such  measures,  but  I 
am  convinced  that  without  them  we  cannot  prevent  the 
spread  of  diphtheria.  It  is  essential,  too,  that  milk 
should  be  boiled  directly  it  is  delivered  at  the  house  and 
set  aside  to  cool,  bread  should  be  well  scraped,  fruit 
should  be  peeled  or  cleansed,  and  vegetables  should  be 
thoroughly  washed.  It  is  much  more  difficult  to  prevent 
infection  by  persons  who,  without  themselves  being  ill, 
harbour  the  virulent  germs  of  the  disease  in  the  nasal 
cavity  and  throat.  Often,  as  in  the  cases  rejDorted  by 
Escherich  in  which  the  infection  was  spread  by  a 
nurse,  it  is  by  a  mere  chance  that  we  find  the  source 
of  the  infection,  and  we  must  therefore  carefully  weigh 
all     possibilities     and     endeavour    to     arrive     at    a    con- 

473 


THE  PEEVENTION"  OF  DISEASE 

elusion  by  tlie  help  of  bacteriological  examinations.  The 
child  suffering  from  diphtheria  and  all  its  surroundings, 
those  whose  duty  it  is  to  nurse  the  child  as  well  as  all 
things  which  are  used  for  the  child,  require  very  special 
care.  The  precautions  by  way  of  disinfection  which  have 
already  been  described  in  detail  in  previous  pages  must 
be  strictly  observed.  It  seems  to  me  important  that  we 
should  make  sure  by  examination  of  cultures  that  the 
disease  is  of  a  diphtheritic  nature,  this  being  of  the 
greatest  importance  both  as  regards  the  treatment  of  the 
disease  and  the  subsequent  measures  to  be  taken.  I  do 
not  deny  that  there  are  certain  obstacles  in  the  way  of 
introducing  this  method  into  general  practice,  but  these 
must  be  removed.  The  brilliant  results  obtained  in  places 
where  it  is  carried  out  are  the  best  guarantee  for  the 
correctness  of  these  statements.  Another  equally  im- 
portant point  is  that  a  child,  though  convalescent  after 
diphtheria,  and  this  may  be  in  a  few  days  when  serum  has 
been  early  used,  harbours  virulent  diphtheria  bacilli  for  a 
long  time  in  its  throat,  though  the  mucous  membrane  is 
apparently  normal,  and  also  in  its  saliva,  and  in  this  way 
infection  may  be  spread.  We  should  therefore,  before  dis- 
pensing with  further  isolation,  examine  the  mouth  of  the 
child  for  these  bacilli,  and  by  gargling  with  solution  of  cor- 
rosive sublimate,  mopping  out  the  throat  with  this  antiseptic, 
and  in  other  similar  ways,  endeavour  to  render  innocuous 
any  bacilli  which  still  remain.  When  for  other  reasons 
it  is  not  possible  to  do  this,  isolation  of  the  child  must  be 
strictly  carried  out  till  we  are  sure  that  the  throat  is  quite 
clear,  and  this  often  takes  several  weeks  after  the  exudation 
has  gone.  This  point  is  also  of  the  greatest  importance 
in  relation  to  the  return  of  the  child  to  school. 

As  to  the  brothers  and  sisters  it  is  advisable  to  remove 
them  from  the  house  directly  after  the  illness  has  declared 
itself ;  generally  it  is  possible  by  this  early  isolation  to 
keep  them  from  becoming  infected,  and  it  is  essential 
that  they  be  kept  under  observation  so  that  at  the  very 
first  appearance  of  symptoms  they  may  be  submitted  to 
the  serum  treatment.     When  it  is  impossible  to  separate 

-474 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

tliem  tlius  completely  from  tlie  infected  cliild  I  inject  a 
small  dose  of  Beliring's  serum  sufficient  to  render  tliem 
immune  against  diphtheria,  and  in  some  cases  I  have 
followed  the  same  course  with  the  attendants  upon  the 
child.  In  this  way  we  can  remove  all  fear  of  infection 
for  a  few  weeks  and  the  sick  room  can  be  disinfected. 
The  return  to  school  of  the  brothers  and  sisters  of  the  child 
must  be  strictly  forbidden,  especially  as  the  incubation 
period  of  diphtheria  varies  within  such  wide  limits  that 
we  cannot  definitely  state  any  exact  period.  Any  inter- 
course of  the  healthy  children  with  the  attendants  upon 
the  sick  child  should  be  wholly  avoided  where  possible, 
or  should  only  be  allowed  when  all  due  precautions  are 
taken :  that  is,  there  should  be  no  close  contact  and  the 
clothes  should  be  changed.  Among  preventive  measures 
calculated  to  prevent  possible  complications  I  give  the 
foremost  place  to  the  early  use  of  the  serum.  Its  use  in 
more  than  a  hundred  cases  in  private  practice,  some  of  them 
in  consultation  with  other  physicians,  has  convinced  me  that 
only  in  this  way  can  we  make  sure  that  the  disease  shall 
run  its  course  without  complications  and  disturbance.  The 
results  in  hospitals  have  been  less  uniform  :  they  generally 
do  not  come  under  treatment  till  a  much  later  stage.  It  is 
then  impossible  to  neutralize  the  changes  wrought  by  the 
bacillus  or  its  toxin.  During  the  last  few  years  I  have 
seen  no  case  complicated  with  albuminuria  or  nephritis 
and  no  paralysis,  and  since  using  this  valuable  serum  there 
has  not  been  any  rash.  "We  should  not  omit  to  wash  out 
the  throat  regularly ;  appetite  returns  earlier  when  this 
is  done  and  any  microbes  which  would  produce  secondary 
infections  are  best  removed  by  this  method.  In  hospitals 
where  no  provision  is  made  for  treating  dijohtheria  separately 
we  should  adopt  preventive  inoculation  as  introduced  by 
Heubner  and  persuade  all  patients  to  undergo  the  opera- 
tion ;  the  value  of  this  prophylactic  is  shown  by  the  total 
disappearance  of  infection  in  the  institution. 

As  in  most  of  the  acute  infectious  diseases,  so  too  in 
whooping  cough,  the  exciting  cause  of  the  disease  is  still 
unknown  :  much  work  has  been  done  in  this  field  during 

475 


THE  PEEVENTION  OE  DISEASE 

recent  years  but  the  results  liave  been  so  contradictory  as 
to  be  of  no  value  yet  for  practical  purposes.  Of  the  three 
stages  of  the  disease — the  stage  of  prodromal  catarrh,  the 
convulsive  stage,  and  the  stage  of  decline — the  first  is  the 
most  dangerous,  not  I  think  because  of  its  greater  in- 
fectiousness, but  because  the  disease  has  not  yet  been 
diagnosed  and  close  intercourse  with  other  children  has 
not  been  forbidden.  Diagnosis  in  this  initial  stage  would 
be  of  great  service  in  preventing  pertussis,  and  I  venture 
to  suggest  that  we  should  look  with  suspicion  upon  every 
cough  the  severity  of  which  is  disproportional  to  the 
physical  signs  and  which  is  not  relieved  by  sedatives,  and 
should  isolate  such  children.  Though  some  authorities  do 
not  consider  the  paroxysmal  stage  to  be  contagious  yet 
this  is  surely  an  error,  and  I  would  urge  isolation  of  the 
patient  with  whooping  cough  until  complete  cessation  of 
the  cough.  The  difficulty  of  isolation  is  greatly  increased 
by  the  fact  that  we  have  to  do  mostly  with  patients  who 
do  not  keep  to  their  room  or  their  bed  but  go  out,  especi- 
ally in  the  fine  seasons  of  the  year,  against  the  wish  of 
the  physician.  Certain  special  precautions  are  required 
that  the  j^atient  may  have  open-air  treatment  and  at  the 
same  time  that  the  danger  of  conveying  infection  to  others 
may  be  reduced  to  a  minimum.  I  would  recommend  that 
certain  parts  of  parks  should  be  reserved  and  laid  out 
for  such  children,  that  special  conveyances  should  be  used 
to  bring  patients  living  at  a  distance,  that  j^arents  or 
attendants  accompanying  the  children — who  are  often  so 
thoughtless  about  this  matter — should  be  advised  to  take 
the  child  aside  at  the  apj^roach  of  a  paroxysm  of  coughing 
and  to  see  that  the  expectoration  is  received  into  a  cloth 
which  can  later  be  thoroughly  disinfected,  or  else  that 
the  expectoration  is  at  once  covered  over  by  earth.  This 
method  is  not  always  practicable,  especially  when  the 
paroxysms  are  followed  by  severe  vomiting  and  the  food, 
mixed  with  infectious  mucus  from  the  larynx,  cannot  be 
got  rid  of  so  easily  ;  nevertheless  much  can  be  done  by 
removing  certain  bad  habits,  such  as  drawing  the  mucus 
out  of  the  mouth  of  the  child  with  the  fingers,  smearing 

476 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

it  on  the  clothes,  and  holding  the  child  up  against  the 
body  during  the  paroxysm.  Similar  precautions  should 
be  taken  too  at  the  various  watering  places  and  summer 
resorts  to  which  children  with  whooping  cough  are  taken. 
And  here  too  it  would  be  advisable  to  set  apart  certain 
places  where  such  patients  with  their  attendants  would 
only  be  received  and  where  the  houses,  the  walks  and  the 
entire  arrangements  of  life  could  be  adapted  to  the  needs 
of  such  children.  These  are  very  desirable  precautions  and 
would  most  effectually  prevent  the  spread  of  the  disease. 
In  railway  travelling  special  carriages  should  be  set  aside 
for  such  children  and  indeed  for  all  persons  suffering  from 
contagious  diseases ;  these  should  be  such  as  can  be  easily 
disinfected,  and  each  carriage  should  be  thoroughly  cleaned 
after  every  journey.  Lastly,  it  should  be  mentioned  that 
it  is  best  to  avoid  treating  children  with  whooping  cough 
in  institutions  on  account  of  the  risk  run  of  developing 
secondary  infections.  Thorough  disinfection  of  the  house 
in  which  a  case  of  whooping  cough  has  been  is  essential. 
The  child  should  be  kept  away  from  school  till  the  cough 
has  completely  ceased.  As  to  the  brothers  and  sisters  they 
should  be  removed  from  the  house,  and  should  not  be 
allowed  to  go  to  school  unless  they  have  already  had 
whooping  cough  or  until  they  have  had  no  intercourse 
whatever  with  the  patient  for  about  a  fortnight,  this  being 
the  incubation  period.  Children  at  the  breast  should  also 
be  removed  from  the  house,  for  although  there  is  certainly 
some  immunity  against  pertussis  in  a  child  who  is  suckled, 
yet  when  it  does  take  the  disease  it  has  it  in  a  very  severe 
form  which  often  ends  fatally. 

Conveyance  by  a  third  person  is  possible,  especially 
through  expectoration  clinging  to  clothes  or  toys  or  utensils 
used  by  the  sick  child,  and  it  can  be  prevented  by  suitable 
precautions,  such  as  changing  the  clothes  before  visiting 
the  other  children,  thorough  cleansing  of  dishes  and  vessels 
used  for  eating  and  drinking,  and  by  destruction  of  the  toys 
at  the  end  of  the  illness. 

A  few  words  must  here  be  said  about  the  prevention  of 
complications    which  may  be  very  severe  even  when  the 

477 


THE   PREVENTION   OF   DISEASE 

disease  has  run  a  mild  course.     The  coincidence  of  epidemics 
of  pertussis  and  measles,  reference  to  which  has  already- 
been  made,  demands  serious  attention,  because  these  diseases 
have  a  bad    influence  one  on   the   other   and  favour   the 
development  of  tuberculosis.     At    such    times   we   should 
therefore  exercise  extra  care  to   prevent    infection.      The 
open-air  treatment  of  pertussis  is  an  additional  precaution : 
every   physician  knows  the  fact,  though  the  explanation 
of  it  is  not  yet  forthcoming,  that  the  number  of  paroxysms 
of  whooping  cough  is  far  smaller  in   the   open   air  than 
indoors.      I  attribute  also  to  this  factor  the  good  results 
supposed  to    follow  a  change   into   the   country,   and   we 
should  therefore  send   the   children   into   the  open  air  as 
much  and  as  long  as  possible.     But  we  must  not  forget 
that  these  patients   are   thereby  exposed  to    the    risk  of 
taking  cold  and  of  developing  complications  of  the  respir- 
atory tract  which  may  be  very  serious.      The  child  should 
therefore   be  permitted  to  be  out  of   doors  for   long  only 
in  the  warm  season  of  the  year  and  on   dry  days  when 
there  is  no  wind,  but  in  autumn  and  in  winter  he  should 
only   be  out   in  the   afternoon   when   the  sun  is  shining. 
The  advice  now  often  given  that  the  child  ill  with  whoop- 
ing cough  should  be    carried  out    in    the  open  air   even 
when   the   disease   is   complicated   with   pneumonia   is,   I 
consider,  very  dangerous. 

When  speaking  about  measles  I  pointed  out  that  measles 
and  whooping  were  peculiar  in  that  they  render  a  child 
very  susceptible  to  the  infection  of  tuberculosis,  or  may 
render  active  some  latent  tendency  to  tuberculosis,  especially 
of  the  bronchial  glands.  "Wherever  there  is  an  hereditary 
disposition  or  whenever  there  is  much  risk  of  infection 
extra  care  is  required  to  prevent  the  tubercle  bacilli  from 
gaining  a  hold.  It  is  best  at  once  to  remove  the  child  out 
of  these  infected  areas,  and  if  tuberculous  disease  of  these 
glands  is  already  present  we  must  secure  the  most  favour- 
able conditions  possible  by  getting  the  child  into  the 
country  and  by  proper  diet,  in  order  to  render  the  attack 
of  whooping  cough  as  mild  and  as  short  as  possible.  In 
the  dieting  too  we  have  some  prophylactic  opportunities  : 

478 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

frequent  vomiting  reduces  tlie  pliysical  strength  of  the 
child  and  makes  it  less  able  to  resist  secondary  infections  ; 
in  these  cases,  as  indeed  in  all  cases  of  pertussis,  the  child 
should  have  frequent  meals,  most  of  them  consisting  of 
fluids  or  gruel ;  the  meals  should  be  taken  shortly  after 
a  paroxysm  of  coughing  in  order  that  there  may  be  an 
interval  for  the  partial  absorption  of  food  before  the  next 
attack. 

In  the  infective  diseases  which  so  far  have  been  de- 
scribed, the  infection  was  conveyed  chiefly  by  direct  contact 
or  inhalation  or  through  a  third  person  or  through  some 
object ;  but  in  typhoid  fever  it  is  somewhat  different :  the 
patient  has  become  infected  by  eating  or  by  drinking  infected 
substances  which  contain  the  specific  bacillus,  and  other 
modes  in  which  infection  may  be  conveyed  are  of  secondary 
importance  only.  Most  often  the  infection  is  through 
drinking  water  made  impure  by  having  become  mixed  with 
the  excreta  from  a  typhoid  patient,  or  through  unboiled 
milk  containing  the  bacillus,  through  badly  washed  veget- 
ables or  unpeeled  fruit.  It  is  only  rarely  that  a  person 
becomes  infected  directly  by  the  secretions  and  excretions 
of  the  patient.  The  aetiology  is  more  obscure  in  those 
cases  where  an  infant  at  the  mother's  breast  is  attacked 
with  typhoid  fever  though  neither  the  mother  nor  the 
wet  nurse  has,  or  has  had,  the  disease.  I  have  several  times 
seen  such  cases  in  Prague,  which  has  the  evil  reputation  as 
a  typhoid  fever  locality.  "We  can  only  surmise  that  the 
bacillus  was  in  the  water  used  for  washing  the  breasts 
or  in  the  bath  water,  or  that  the  bacillus  reached  the 
finger  of  the  nurse  in  some  way  and  was  conveyed  to  the 
child's  mouth  when  the  nurse  was  attending  to  the  child. 
The  preventive  measures  against  such  sources  of  infection 
are  obvious  :  boiled  water  alone  should  be  used  for  washing 
the  breasts  or  for  the  child's  bath,  and  the  hands  should  be 
well  washed  before  touching  the  child.  If  there  is  a  case 
of  typhoid  fever  in  the  house  the  patient  should  be  isolated 
and  every  care  be  taken  to  prevent  the  infection  being 
conveyed  to  the  infant.  If  the  child  is  being  artificially 
fed  the  main  point  is  the  thorough  boiling  of  the  milk, 

479 


THE  PREVENTION   OF  DISEASE 

and  only  boiled  water  should  be  used  to  dilute  tbe  milk. 
In  the  ]3eriod  of  early  childliood  additional  measures  are 
required :  drinking  water,  especially  in  towns  where  there 
is  much  typhoid  fever,  should  always  be  boiled  and  filtered 
or  replaced  by  a  mineral  water ;  all  food  given  to  the 
child  should  previously  have  been  well  cleaned,  and  this 
is  especially  the  case  with  fruit,  which  should  be  peeled 
or  thoroughly  washed.  Especially  during  epidemics  one 
must  be  careful  about  children  who  like  to  play  with 
earth,  and  one  should  prevent  the  child  putting  its  fin- 
gers to  its  mouth  before  they  have  been  washed.  "When 
the  disease  is  present  the  chief  aim  must  be  to  disin- 
fect the  faeces  and  urine  to  prevent  spread  of  the 
infection  ;  the  excreta  should  be  disinfected  by  the  ad- 
dition of  lime  ;  the  linen  should  be  separately  washed, 
having  previously  been  put  into  a  solution  of  corrosive 
sublimate ;  the  hands  of  those  who  are  attending  the 
patient  should  be  carefully  cleansed  and  disinfected  with 
corrosive  sublimate,  soap,  alcohol  and  ether.  By  observ- 
ing these  precautions  it  is  generally  possible  to  prevent 
the  brothers  and  sisters  from  becoming  infected,  and  with 
suitable  home  arrangements  they  may  be  allowed  to  go 
to  school,  especially  as  the  very  slow  development  of 
typhoid  fever  would  make  it  possible  to  take  them  away 
from  school  in  time. 

Among  ]3reventive  measures  we  must  include  the  making 
of  a  correct  diagnosis  of  typhoid  fever  and  this,  as  every 
experienced  physician  knows,  is  very  difficult  at  the  begin- 
ning of  the  illness.  "We  should  therefore  avail  ourselves 
of  every  possible  means  of  diagnosis,  make  cultures  from 
the  faeces  and  urine,  and  apply  "Widal's  test :  where 
circumstances  do  not  permit  of  this  being  done  in  the 
physician's  own  laboratory,  the  sanitary  authorities  should 
provide  facilities  which  would  enable  this  method  of 
examination  to  be  added  to  the  other  methods  for  the 
diagnosis  of  infectious  disease.  If  the  State  imposes  upon 
the  physician  the  duty  of  notification  of  infectious  disease 
it  should  also  on  its  part  place  every  available  method  for 
the  diagnosis  of  disease  at  his  disposal,  free  of  charge  and 

480 


THE  PREVENTION  OE  THE  DISEASES  OF  CHILDREN 

without  taking  up  much  of  his  time :  this  is  indispensable 
in  the  interests  both  of  public  and  private  hygiene. 

It  is  necessary  now  for  me  merely  to  mention  the  pre- 
vention of  complications.  The  mouth  must  be  kept 
thoroughly  clean  as  it  is  often  the  site  of  numerous  bacteria 
which  may  excite  secondary  infections  ;  great  care  must 
be  given  to  the  care  of  the  skin  ;  the  genito-anal  region 
should  be  kept  clean.  A  large  amount  of  fluid  should  be 
given  to  the  patient,  and  the  diet  should  be  ample  and  such 
as  not  to  give  rise  to  irritation  of  the  intestinal  tract.  Great 
importance  should  be  attached  to  deciding  upon  the  time 
when  the  patient  may  get  up  and  when  solid  food  may 
again  be  given ;  too  great  haste  may  be  the  cause  of  much 
mischief.  So  far  as  one  can  make  general  rules  for  these 
cases,  I  never  allow  a  patient  to  get  up  before  the  com- 
mencement of  the  second  week  after  the  temperature  is 
quite  normal.  I  allow  solid  food  to  be  given  at  the  same 
time,  and  a  week  later  I  permit  the  patient  to  go  out  in  the 
open  air  in  good  weather. 

Epidemic  parotitis,  or  mumps,  runs  a  very  favourable 
course  in  childhood,  and  cases  complicated  with  orchitis 
are  much  more  rare  than  in  adults.  This  consideration 
induces  some  authorities  to  suggest  that  measures 
should  not  be  taken  to  prevent  children  from  acquiring 
this  infection,  because  infection  during  childhood  will 
render  them  immune  against  infection  later  in  life  when 
the  disease  runs  a  more  severe  course.  "When  speaking 
of  scarlatina  I  pointed  out  that  we  are  not  justified 
in  adopting  this  course,  and  for  mumps  I  would  simi- 
larly urge  the  isolation  of  the  patient,  the  disinfection 
of  all  articles  used  by  the  patient,  keeping  the  patient  and 
his  brothers  and  sisters  away  from  school,  and  thorough 
disinfection  of  the  house  when  the  disease  is  over.  These 
principles  I  have  already  laid  down  in  detail.  It  should 
be  remembered  that  the  infectiousness  of  mumps  begins 
with  the  prodromal  stage  and  lasts  during  the  whole 
course  of  the  disease,  and  the  incubation  period  extends 
over  two  or  three  weeks. 

During    the  last  ten  years  Europe  has  repeatedly  been 

481  II 


THE  PEEVENTION  OF  DISEASE 

visited  by  widespread  and  in  parts  by  very  severe  forms 
of  influenza.  It  may  attack  cliildren  during  all  periods  of 
child  life,  and  its  very  rapid  spread  and  infectiousness, 
make  its  prevention  a  difficult  task. 

It  is  a  very  dijSicult  matter,  especially  in  cases  where 
the  mother  or  wet  nurse  has  influenza  ;  taking  the  child 
from  the  breast  does  not  save  it  from  infection,  and  on  the 
other  hand  exposes  the  infant  to  the  risks  run  by  changing 
its  food,  and  many  an  infant  has  succumbed.  From  the 
experience  gained  in  the  three  epidemics  of  influenza  which 
have  visited  Prague  since  1890,  I  am  of  opinion  that  isola- 
tion of  the  patient  is  of  very  little  value  ;  it  is  generally 
not  possible  to  isolate  these  cases  till  too  late,  and  the 
disease  spreads  so  rapidly  and  by  so  many  ways  over  whole 
towns  and  regions  that  it  is  quite  impossible  to  attack 
them  all,  and  it  is  better  to  look  on  with  a  certain  fatal- 
ism. At  all  events  I  do  not  advise  that  children  should  be 
sent  away  from  the  infected  house,  which  would  only  still 
further  spread  the  malady,  neither  do  I  advise  that  a 
change  should  be  made  in  the  feeding  of  an  infant  at  the 
breast  unless  the  disease  is  running  so  severe  a  course  as  to 
influence  unfavourably  the  secretion  of  milk.  It  appears 
to  me  to  be  of  much  greater  importance  to  prevent  second- 
ary infections  proceeding  from  the  mouth  and  nose,  and 
most  of  these  are  caused  by  streptococci.  These  infections 
are  often  seen  in  children,  and  they  are  of  bad  prognosis, 
whereas  the  prognosis  of  the  disease  itself  is  good.  Regu- 
lar washing  out  of  the  throat  and  nose  with  lukewarm 
boracic  acid  solution  seems  best  to  prevent  these  infections. 
Large  numbers  of  people  are  attacked  at  a  time,  and  it 
seems  therefore  advisable  in  the  case  of  school  children 
that  the  school  should  be  closed  to  prevent  at  least  this 
source  of  spread  of  infection.  I  am  not  able  to  say  whether 
disinfection  of  the  room  or  rooms  in  which  the  patient  has 
been  is  of  any  value ;  the  attempt  might  be  made.  I  did 
not  myself  make  it,  because  in  the  families  to  which  I  was 
called  all  the  members  generally  sickened  in  such  rapid 
succession  that  subsequent  disinfection  of  the  house  ap- 
peared unnecessary. 

482 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

My  experience  in  miliaria  is  limited,  and  extends  only 
to  a  slight  epidemic  ■which  occurred  in  an  outlying  district 
of  Prague.  The  infectious  nature  of  these  cases  was  but 
slight :  isolation  of  the  patient  in  one  room  sufficed  to  pre- 
vent the  brothers  and  sisters  from  becoming  infected,  and 
disinfection  of  the  sick  room  sufficed  to  destroy  the  ap- 
parently short-lived  germs.  But  from  communications 
made  by  various  authorities  I  gather,  that  in  some  epi- 
demics of  miliaria  the  disease  runs  a  very  severe  course 
and  is  highly  infectious,  and  in  such  cases  it  is  obvious 
that  far  more  stringent  preventive  measures  are  required. 

Glandular  fever  was  first  described  by  Emil  Pfeiffer,  but 
some  do  not  consider  it  a  special  disease.  I  have  only  seen  a 
few  doubtful  cases  of  it,  and  am  therefore  not  able  to  give 
any  personal  experience  in  regard  to  its  prevention. 
Prague,  so  fertile  a  soil  for  the  various  infectious  diseases, 
does  not,  judging  from  the  observations  of  myself  and  my 
colleagues,  offer  a  favourable  soil  for  this  disease. 

Physicians  who  have  had  exj^erience  with  glandular 
fever  state  that  it  is  not  highly  infectious  ;  they  recom- 
mend that  the  patient  be  isolated,  and  on  recovery  the 
throat  and  nose  should  be  washed  out  several  times,  and 
a  few  baths  containing  some  antiseptic  should  be  given 
before  the  child  is  permitted  to  associate  with  other 
children. 

The  remaining  diseases  comprised  in  this  group  are 
Asiatic  cholera  and  malaria.  I  have  not  seen  a  case  of 
either  of  these  among  children,  and  must  refer  the  reader 
elsewhere. 

Tetanus  is  an  infection  which  may  be  met  with  here 
and  there  during  the  period  of  infancy  and  during  early 
childhood.  In  the  former  period  the  infection  usually 
enters  by  the  umbilical  wound,  and  prevention  lies  in  strict 
asepsis.  During  early  childhood  the  bacillus  usually  gets 
into  the  body  from  the  earth,  and  infection  is  prevented 
by  guarding  the  child  from  all  dirt  and  by  carefully  disin- 
fecting any  small  injury  the  child  may  meet  with.  When 
the  disease  is  epidemic,  as  last  year  at  the  Prague  Lying- 
in  Institution,  it  is  extremely  diffi.cult  even  by  the  most 

483 


THE  PREVENTION  OE   DISEASE 

thorough,  disinfection  to  get  the  upper  hand  of  the  tetanus 
bacillus,  as  may  be  seen  from  the  fact  that  after  leaving 
the  wards  empty  for  a  long  time  and  thorough  cleansing 
of  them,  sporadic  cases  nevertheless  occurred  when  they 
were  again  used.  In  such  a  case,  having  regard  to  the 
doubtful  results  obtained  by  treatment  with  antitoxin,  it 
seems  to  me  best  to  adopt  preventive  inoculation  of  all 
pregnant  patients  taken  into  the  institutions  and  all 
patients  already  confined,  a  method  which  might  also  be 
extended  to  the  children. 

Hydrophobia  is  an  infectious  disease  not  very  rare  in 
early  childhood,  and  I  can  remember  seeing  a  number  of 
young  children  who  were  patients  at  the  Paris  Pasteur 
Institute  in  the  year  1886.  The  preventive  treatment  car- 
ried out  by  Pasteur,  which  is  begun  during  the  incubation 
period,  is  now  practised  in  the  institutes  of  preventive 
medicine  in  various  countries,  and  is  so  well  known  as  to 
need  no  further  description.  Another  method  of  preven- 
tion is  to  forbid  the  child  having  anything  to  do  with 
domestic  animals,  which  often  are  a  source  of  danger  too 
in  other  ways. 

Next  I  turn  to  chronic  infectious  diseases  of  early  child- 
hood and  their  prevention.  Tuberculosis  must  be  first  con- 
sidered. The  conditions  of  infection  and  the  course  of  the 
disease  are  somewhat  different  at  this  period  of  life  from 
those  of  infancy.  In  an  earlier  paragraph  relative  to 
tuberculosis  I  pointed  out  the  dangers  which  are  run  when 
children  hereditarily  predisposed  to  tuberculosis  and  very 
susceptible  to  the  contagion  are  allowed  to  live  with  their 
parents  who  are  already  phthisical :  in  such  cases  it  would 
be  best  to  follow  Heubner's  suggestion,  and  put  the  children 
into  a  special  institution.  This  unfortunately  often 
cannot  be  done,  and  other  preventive  measures  too  against 
tuberculosis  are  very  difficult  to  carry  out  in  practice. 
Often  it  is  absolutely  impossible  to  prevent  close  inter- 
course between  parents  and  children :  to  educate  tuber- 
culous patients,  and  get  them  to  observe  due  caution  in  the 
disposal  of  their  expectoration  and  to  avoid  using  vessels 
in  common  with  others  for  eating  and  drinking,  are  tasks 

484 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

often  beyond  the  power  of  the  physician  to  accomplish, 
thongli  their  importance  is  very  eviflent  and  of  special 
value  for  those  who  are  scrofulous.  At  present  I  see  but 
scant  possibilities  for  such  thorough  preventive  measures, 
and  we  shall  have  for  some  time  to  come  to  be  content 
with  removing  a  part  only  of  these  dangers. 

I  will  now  briefly  describe  these  measures.  Experience 
teaches  us  that  a  large  number  of  children  belonging  to 
tuberculous  parents  have  caseation  of  the  bronchial  lymph- 
atic glands,  the  clinical  diagnosis  of  which  is  not  very 
easy,  but  which  we  may  assume  with  tolerable  certainty 
to  be  present  when  there  is  enlargement  of  many  of  the 
cervical  glands,  especially  of  those  lying  along  the  anterior 
border  of  the  trapezius,  which,  as  I  have  often  verified  by 
■post  mortem  examinations,  are  continuous  with  the  chain 
of  infected  lymphatic  glands  in  the  hilum  of  the  lung.  I 
attach  less  value  to  interscapular  dulness,  or  to  weak 
breath-sounds  of  one  lung  produced  by  narrowing  of  the 
chief  bronchus  by  pressure  upon  it  of  the  surrounding 
lymphatic  glands,  and  the  diagnostic  aid  of  tuberculin 
injection  I  consider  too  dangerous  for  use  in  children. 
Some  of  these  children  do  not  develop  either  a  local  or  a 
general  tuberculosis  ;  in  other  children  the  swelling  of  the 
lymphatic  glands  is  the  result  of  disease  elsewhere,  such  as 
chronic  intestinal  trouble,  nevertheless  I  regard  these  en- 
larged glands  as  a  symptom  which  should  make  us  suspect 
tuberculosis,  especially  when  there  is  a  family  history  of 
tuberculosis  and  the  children  show  any  other  signs  of  the 
disease.     The  greatest  care  is  required  in  these  cases. 

There  are  several  precautionary  measures  to  be  taken : 
all  sources  of  irritation  of  the  lungs,  especially  that  which 
follows  a  cold,  should  be  avoided ;  the  children  should  be 
guarded  against  changes  of  weather,  should  be  much  in 
the  fresh  air,  and  spend  the  fine  months  of  the  year  in 
some  healthy  district,  avoiding  however  all  places  fre- 
quented by  phthisical  patients,  and  selecting  a  spot  where 
there  is  sea  air  or  where  there  are  brine  baths.  The 
tendency  of  some  infectious  diseases,  especially  of  measles 
or  of  whooping  cough,  to  bring  out  a  latent  tuberculosis, 

485 


THE  PEEVENTION   OF  DISEASE 

makes  it  our  duty  to  guard  sucli  cliildren  from  those  diseases 
which  excite  tuberculosis.  They  should  therefore  be  kept 
away  from  children's  ordinary  j^l^-Jgro^^i^cls,  should  be 
watched  when  out  for  a  walk,  should  be  guarded  from  all 
that  would  necessitate  general  intercourse  with  other 
children,  and  should  not  be  sent  to  school  till  they  are 
older,  because  the  risks  are  then  fewer,  as  most  children 
have  the  infectious  diseases  in  early  childhood.  Careful 
diet,  excluding  all  food  that  might  convey  tuberculous 
virus,  and  care  of  the  physical  health  are  essential.  These 
children  are  not  fit  subjects  for  strong  measures  in  harden- 
ing the  body.  All  this  is  naturally  possible  only  for  those 
in  the  better  circumstances  of  life ;  for  the  poor  and 
wretched  the  only  prospect  lies  in  government  help  in  the 
future. 

Another  class  of  cases  which  must  here  be  considered 
contains  those  in  which  scrofulous  symptoms  are  present, 
I  will  not  here  enter  upon  the  question  of  the  relation  be- 
tween scrofula  and  tuberculosis,  but  merely  state  that 
personally  I  regard  scrofula  as  affording  a  favourable  soil 
for  the  development  of  tuberculosis.  It  seems  to  me 
immaterial  whether  this  is  the  correct  view  or  whether 
scrofula  is  of  a  directly  tuberculous  nature.  Experience 
teaches  us  that  with  suitable  treatment  scrofula  may  be 
perfectly  cured,  and  that  children  who  have  had  scrofula 
may  grow  perfectly  strong  in  later  years,  showing  not  a 
trace  of  the  former  scrofulous  diathesis.  The  suscepti- 
bility to  tubercular  virus  disappears  when  these  scrofulous 
symptoms  disappear,  and  this  suggests  one  line  along  which 
preventive  treatment  may  go.  The  advantage  of  this 
treatment  is  not  for  the  rich  alone;  and  poor  people  are 
able  to  send  their  children  to  hospitals  which  have 
been  established  at  seaside  places  through  private  benevo- 
lence. It  were  to  be  wished  that  the  government  would 
actively  take  the  matter  in  hand,  as  is  done  in  France,  be- 
cause the  question  is  one  concerning  the  health  of  the 
rising  generation. 

It  can  be  shown  even  in  childhood  that  there  exists  a 
close  correlation  between  the  heart  and  the  lungs  in  children 

486 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

with  a  tuberculous  predisposition,  and  this  suggests 
another  line  of  preventive  treatment  which  may  be  followed. 
I  have  already  said  that  such  children  should  not  be  sent 
to  school,  this  prevents  the  risk  of  their  infection  with 
infectious  diseases,  but  it  is  well  for  other  reasons  too  to 
keep  the  child  from  school.  Sitting  still  for  hours  at  a  time, 
the  homework,  want  of  movement,  and  the  faulty  position 
assumed  in  reading  and  writing,  are  conditions  which  tend 
to  prevent  the  efficient  expansion  of  the  lungs  and  the 
effective  working  of  the  heart,  and  these  make  it  still  more 
easy  for  Koch's  bacillus  to  develop  in  a  body  predisposed  to 
tuberculosis.  Suitable  gymnastic  exercises  are  of  value, 
but  should  not  be  begun  too  early,  not  till  after  the  sixth 
year,  and  should  be  limited  to  "free  "  movements  and  dumb- 
bell exercises  to  increase  the  size  of  the  thorax  and  raise 
the  respiratory  capacity  of  the  lungs.  Thus  we  possess  a 
number  of  preventive  measures  by  which  one  who  is 
apparently  likely  to  die  or  to  become  chronically  ill  may 
be  transformed  into  an  individual  capable  of  taking  his 
part  in  the  battle  of  life. 

As  regards  syphilis  in  early  childhood,  the  measures 
already  given  when  speaking  of  syphilis  acquired  in  in- 
fancy should  be  adopted.  It  should  be  added  that  sleeping 
with  unknown  persons  should  be  forbidden,  as  is  not  un- 
common among  the  lower  classes  ;  and  even  at  this  early 
age  syphilis  may  be  caused  by  sexual  abuse. 

Before  proceeding  to  speak  of  measures  required  to  pre- 
vent disease  of  the  various  organs  of  the  body,  it  seems 
well  to  say  a  few  words  about  the  care  of  children  and  diet 
at  this  period  of  life,  so  far  as  this  is  concerned  with  the 
prevention  of  disease.  As  to  the  bath,  one  should  begin 
towards  the  later  months  of  infancy  to  discontinue  the 
daily  bath  and  limit  the  baths  to  two  a  week  in  the  period 
of  early  childhood  and  in  winter  to  one  a  week.  The  fact 
that  the  child  gets  about  much  more  necessitates  very  care- 
ful watching  of  its  movements,  and  all  water  which  is 
derived  from  a  suspicious  source,  as  is  the  general  case  in 
Prague,  should  be  boiled  before  being  used.     The  tempera- 

487 


THE  PREVENTION  OF  DISEASE 

ture  of  tlie  bath  in  the  second  year  should  not  be  below  85*^  F., 
and  later,  so  far  as  the  ordinary  bath  is  concerned,  the  tem- 
i:)eratnre  should  be  only  very  gradually  reduced,  and  should 
not  during  early  childhood  be  below  a  minimum  of  70°  F. 

It  is  otherwise  with  bathing  in  the  open,  and  in  fine 
weather  particularly  at  the  seaside  it  is  permissible  to  bathe 
in  water  at  a  lower  temperature :  but  I  would  not  permit 
children  to  bathe  in  the  open  before  the  end  of  the  third 
3^ear,  and  I  would  not  permit  them  to  learn  to  swim  before 
they  are  eight  j^ears  of  age. 

This  question  leads  me  next  to  consider  the  subject  of  the 
hardening  of  the  body,  about  which  we  are  so  often  asked 
for  advice.  I  cannot  say  that  I  am  personally  impressed 
with  its  advantages,  and  the  course  of  years  has  not  con- 
vinced me  that  such  children  show  any  greater  degree  of 
power  of  resistance  to  disease.  To  begin  very  early  with 
such  measures  I  consider  to  be  a  direct  disadvantage,  and 
my  own  opinion  is  that  they  should  never  be  begun  before 
the  fourth  year,  should  then  be  very  gradually  adopted  and 
carried  out  with  common  sense.  The  temjDerature  of  the 
bath  should  be  slowly  reduced  and  the  bath  may  be  followed 
by  an  application  of  cool  water  or  a  douche.  The  child  may 
be  rubbed  down  with  cold  water  before  going  to  bed,  or  if 
this  stimulates  the  child  too  much,  it  may  be  done  after 
getting  up  in  the  morning.  Suitable  clothing  should  be 
pro^dded  and  the  woollen  vest  and  hose  may  be  disused. 
Certain  customs  which  have  arisen  from  vanity  or  from 
lack  of  understanding,  such  as  wearing  short  socks  in 
winter  and  leaving  the  calves  of  the  leg  bare,  I  consider 
erroneous  and  often  injurious ;  and  so  also  on  the  other 
hand  the  coddling  of  children  and  the  anxious  dread  of 
every  breath  of  air  and  the  wearing  of  much  warm  clothing 
may  all  lead  to  injurious  results.  The  hapj)y  medium  is 
required  in  all  these  matters,  and  Spartan  customs  should 
be  avoided,  for  they  are  not  adapted  to  the  climate  of  Ger- 
many with  its  abrupt  changes  of  temperature. 

With  regard  to  the  mouth,  the  treatment  should  be  differ- 
ent to  that  required  in  infancy.  In  the  baby  the  shallow 
toothless  oral  cavity  with  the  short  alveolar  processes,  in  which 

488 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

tlie  food  (mostly  liquid)  remains  a  very  short  time  may,  especi- 
ally under  certain  conditions  previously  mentioned,  require 
very  special  and  careful  treatment.  In  cliildhood  regular 
daily  care  of  the  mouth  is  required.  It  should  be  cleansed 
daily  with  a  soft  brush  and  piece  of  linen  soaked  in  a  weak 
antiseptic  solution,  and  later  it  is  necessary  to  gargle 
with  a  similar  solution  after  every  meal.  It  seems  to  me 
of  great  importance  to  accustom  the  child  early  to  have 
its  throat  inspected ;  this  makes  it  possible  at  onoe  to 
recognize  any  disease  which  may  commence  in  the  throat 
and  makes  it  also  much  easier  for  the  physician  to  examine 
and  treat  the  throat.  The  painful  struggle  with  a  howling 
child  which  has  possibly  been  previously  threatened  with 
the  "  doctor  "  should  be  spared  us,  and  the  use  of  force,  such 
as  holding  the  nose  till  the  mouth  is  opened  and  using  a 
gag,  should  be  had  recourse  to  only  in  extremity.  The 
care  of  the  teeth  should  be  commenced  with  the  milk  teeth, 
and  as  any  carious  cavity  may  become  the  habitat  of 
numerous  microbes,  it  should  be  stopped  to  make  it  harm- 
less. As  to  the  nose,  I  consider  that  washing  out  of  it  is 
only  necessary  when  there  is  some  infective  process  ;  at 
other  times  it  is  sufficient  to  wash  the  easily  accessible 
parts.  The  same  holds  good  for  the  ears,  which  the  child 
likes  so  much  to  handle  at  this  age,  and  which  therefore 
often  become  affected  with  inflammations  of  the  external 
meatus,  or  stopped  up  with  cerumen  or  foreign  bodies. 

We  must  never  omit  to  inspect  and  to  cleanse  the 
genitals :  conditions  (especially  balanitis  and  vaginal 
catarrh)  associated  with  the  irritation  of  itching  often 
produce  masturbation  which  one  is  almost  powerless  to 
remove  when  once  it  has  developed.  Intestinal  parasites 
too,  especially  threadworms,  may  wander  into  the  vagina 
and  by  mechanical  irritation  cause  pruritus,  leucorrhoea 
and  similar  conditions,  the  cause  of  which  may  be  over- 
looked.    Inspection  of  these  parts  is  therefore  advisable. 

In  regulating  the  life  of  such  children  we  should  aim  at 
letting  them  be  out  of  doors  as  long  as  possible  when  the 
weather  permits,  and  when  they  can  walk  they  should  be 
permitted  to  take  plenty  of  exercise.     The  amount  of  walk- 

489 


THE  PEEVENTIOX   OF  DISEASE 

ing  permitted  to  chiklreii  just  learning  to  walk  or  to  rickety 
children  must  be  limited.  When  the  child  soon  tires  and 
cannot  run  well  the  chief  cause,  in  my  experience,  is  to  be 
found  in  flat  foot  caused  by  rickets  and  generally  combined 
■with  genu  valgum.  When  we  have  convinced  ourselves. 
after  inspecting  the  child  when  it  has  been  stripped,  that  it 
is  suffering  from  rickets  and  the  bones  are  still  soft,  walk- 
ing should  be  forbidden  ;  but  in  other  cases  it  is  sufficient 
to  order  suitable  pads  for  the  boots,  and  they  should  be 
worn  also  in  the  house  till  the  foot  has  become  normal  in 
form. 

Certain  details  need  mention  as  to  the  child's  bedding, 
and  as  to  carrying  the  child  about.  A  firm  mattress  and 
a  low  and  firm  pillow  are  best ;  the  child  should  lie  on  its 
back  in  bed  and  be  lightly  covered  over ;  these  precautions 
will  tend  to  prevent  rachitic  curvature  of  the  spine.  The 
child  should  take  very  little  liquid  with  the  last  meal  and 
the  bladder  should  be  emptied  before  going  to  bed ;  these 
are  the  best  preventive  measures  against  nocturnal  enuresis. 
To  prevent  the  development  of  scoliosis  the  child  should  not 
be  carried  on  the  same  arm  alwaj^s  ;  indeed  it  should  never 
be  carried  for  long,  but  should  be  taken  out  in  a  perambu- 
lator. 

As  to  sleep,  it  is  most  important  that  the  child  should 
sleep  long  and  undisturbed  ;  till  the  end  of  the  third  year 
of  life  it  should  have  several  hours'  rest  in  the  morning  and 
afternoon.  After  three  years  of  age,  only  in  the  afternoon, 
and  this  should  not  be  discontinued  till  it  is  five  or  six 
years  of  age.  The  child  should  be  put  to  bed  early  and  all 
exciting  games  or  tales  should  be  avoided  which  may  dis- 
turb sleep  and  cause  night  terror  and  similar  conditions. 

Their  toys  should  be  as  simple  as  possible,  free  from 
all  poisonous  materials,  and  so  shaped  that  the  child 
cannot  injure  itself  with  them  ;  we  should,  too,  be  careful 
where  they  come  from,  as  they  may  be  carriers  of  in- 
fection. 

Although  games  out  of  doors  are  very  desirable,  yet 
much  coming  into  contact  with  the  earth  should  be  avoided 
as   much    as    possible ;   different   germs    and    the    eggs    of 

490 


THE    PEEVENTIOX  OF  THE  DISEASES  OF  CHILDREN 

intestinal  parasites,  such  as  the  ascaris  lumbricoides,  may 
get  on  to  the  fingers  from  the  earth,  and  as  children  often 
have  the  habit  of  putting  their  fingers  in  the  mouth,  the 
germs  may  thus  obtain  entry  into  the  body. 

As  to  diet,  the  principal  food  up  to  the  end  of  the  second 
year  should  be  milk,  and  variety  can  be  obtained  by  suit- 
able combinations  of  milk  foods,  soups  and  eggs.  Through- 
out childhood  milk  should  be  given  to  the  child  to  drink, 
I  like  to  avoid  the  addition  of  any  coffee  or  tea  because  of 
their  stimulating  effects :  but  I  permit  cocoa  or  chocolate. 
Meat  should  not  be  given  before  the  fourth  half-year  of  life, 
and  it  is  well  not  to  give  any  meat  till  the  child  is  two 
years  of  age.  It  should  be  given  only  once  a  day,  and  I 
prefer  the  different  kinds  of  white  meat  and  fish  without 
bones,  which  can  all  be  given  to  the  child  hashed,  with  or 
without  the  addition  of  eggs.  Before  the  complete  develop- 
ment of  the  milk  teeth  meat  should  not  be  given  except  very 
finely  cut  up,  otherwise  the  morsels  which  are  but  slightly 
masticated  undergo  decomposition  in  the  intestine  and 
cause  diarrhoea.  I  must  protest  strongly  against  giving 
children  raw  meat :  the  dangers  of  raw  meat  outweigh  its 
advantages,  for  ova  or  intermediate  stages  of  intestinal 
parasites  or  other  organized  causes  of  disease  and  the  toxins 
produced  by  them  get  into  the  child's  body  through  the 
raw  meat.  For  the  same  reason  no  meat  should  be  given 
to  the  child  which  is  not  quite  fresh  or  which  has  been 
insufficiently  boiled  or  roasted ;  it  should  not  be  eaten 
merely  smoked  or  steamed. 

Among  beverages  alcohol  must  be  avoided  in  every  form  ; 
though  I  do  not  fear  its  use  as  much  as  do  total  abstainers, 
who  paint  its  effects  in  too  dark  colours.  Though  cases  of 
acute  or  of  chronic  alcoholic  poisoning  in  chiMhood  are 
curiosities  rather  than  practical  difficulties,  yet  we  can 
trace  a  decidedly  harmful  influence  of  alcohol  upon  the 
nervous  system,  and  we  should  not  early  accustom  a  child 
to  take  a  substance  to  which  so  many  human  beings  later 
in  life  fall  victims.  For  this  reason  and  also  because,  when 
they  are  at  table  with  adults,  children  have  things  given 
them  which  are  indigestible,  it  is  best   to  keep   children 

491 


THE   PP.EVENTION   OF  DISEASE 

away  from  the  meal  table  of  adults  until  the  little  ones 
may  eat  what  is  on  the  table,  that  is  until  they  are  four 
years  of  age. 

A  few  words  must  also  be  said  as  to  the  regulation  of 
children's  lives.  The  tendency  of  the  present  day  to  hurried 
living  influences  childhood  too,  and  when  we  recall  to 
memory  our  own  early  years  we  are  often  astonished 
at  the  games  and  picture  books  placed  before  children, 
for  they  give  ideas  to  the  young  children  which  formerly 
were  not  given  till  much  later.  Even  their  entertainment 
of  friends  has  taken  a  form  which  appears  to  be  a  reproduc- 
tion on  a  smaller  scale  of  the  dinner  parties  of  adults,  and 
the  children  are  overloaded  with  very  indigestible  food  and 
evince  a  certain  affectation  in  their  intercourse  which  often 
lays  the  foundation  for  the  affected  manners  so  often  seen 
in  girls  and  which  may  be  the  germ  of  a  later  hysteria. 
But  other  ill  results,  especially  the  spread  of  infectious 
diseases,  also  follow  this  social  intercourse  among  children, 
and  I  would  therefore  urge  from  the  purely  medical 
and  prophylactic  aspect  of  the  subject,  and  entirely  omit- 
ting the  educational  aspect,  that  the  intercourse  of  children 
with  other  children  should  be  restricted  to  a  few  well 
known  playmates. 

Another  bad  custom  which  is  unfortunately  very  common 
and  should  be  avoided  as  liable  to  cause  ultimate  mischief 
is  the  overburdening  of  their  minds  by  tasks  of  memory 
intended  to  show  their  intellectual  forwardness.  The 
minds  of  children  are  sufficiently  burdened  with  the  daily 
increasing  number  of  impressions  which  come  to  them 
without  the  addition  of  the  task  of  learning  poems  by  heart. 

Lastly  I  must  speak  of  the  home,  and  point  out  the 
injurious  effects  of  rooms  with  insufficient  air  and  light, 
the  removing  into  newly  built  houses,  especially  during 
winter,  and  the  proximity  of  stables  to  the  house,  factors 
which  have  an  undeniable  influence  upon  the  mortality  of 
children. 

The  evil  effects  of  schools  upon  the  health  will  be  more 
minutely  detailed  under  the  disorders  peculiar  to  later 
childhood. 

492 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDKEN 

I  pass  un  to  consider  the  jDreventive  treatment  of  the 
diseases  of  the  various  organs  of  the  body  during  early 
childhood,  and  begin  with  the  resj)iratory  tract,  including 
the  affections  of  those  jiarts  which  are  common  to  the  passage 
of  food  and  air,  the  mouth  and  pharynx.  The  various  forms 
of  tonsilitis  come  first  in  importance :  they  begin  with  the 
commencement  of  the  second  year  of  life,  and  are  most 
common  in  the  period  of  early  childhood.  Colds  and  infec- 
tious influences  assist  to  cause  them ;  in  the  so-called 
chronically  recurring  exudative  forms  there  is  also  an  here- 
ditary factor ;  the  condition  of  the  mouth  and  teeth  must 
also  be  taken  into  consideration  and  preventive  treatment 
adapted  to  these  various  causes.  One  should  avoid  coddling, 
particularly  the  wrapping  up  of  the  throat  with  warm 
scarves.  The  children  should  be  guarded  against  sudden 
changes  of  temj^erature,  especially  at  school,  where  during 
the  intervals  the  children  are  often  sent  out  of  the  over- 
heated classrooms  into  the  cold  corridors.  The  mouth  and 
teeth  should  be  carefully  cleansed,  and  carious  teeth  should 
be  stopped.  All  cases  of  tonsillitis  are  infectious,  and  such 
patients  should  be  isolated  ;  the  short  duration  of  the  con- 
tagion makes  further  measures  unnecessary,  but  we  must 
wait  till  every  trace  of  the  throat  affection  has  disapi^eared 
before  allowing  the  child  to  return  to  school.  To  avoid 
complications,  some  of  which  run  a  very  serious  course,  the 
nose  and  throat  should  be  well  washed  out  with  large 
quantities  of  weak  antiseptics,  but  I  have  very  little  opinion 
of  the  effects  produced  by  gargling.  The  children  should 
learn  to  gargle  early  so  that  the  mouth  is  kept  thoroughly 
clean,  but  in  cases  of  illness  I  do  not  consider  it  necessary 
to  worry  them  much  with  it.  Cellulitis  and  retropharyn- 
geal suppuration,  which  is  not  rare  at  this  age,  need  timely 
incisions  to  prevent  the  pus  from  going  lower.  Removal  of 
the  tonsils  is  advised  by  many,  esj)ecially  in  chronic  forms 
of  the  affection,  but  I  do  not  consider  that  the  o^^eration  is 
indicated  unless  the  tonsils  are  so  large  as  to  obstruct 
respiration.  I  am  not  of  opinion  that  this  ©ijeration,  which 
has  dangers  of  its  own,  is  a  sure  means  of  preventing  a 
recurrence   of   the  tonsilitis  ;    indeed  I  have   often   seen  a 

493 


THE   PREVENTION  OE   DISEASE 

reciuTence  on  the  scar  surface.  The  same  is  true  for  the 
slitting  up  of  the  follicles  and  other  methods  undertaken 
for  the  same  object.  It  seems  to  me  suitable  here  to  speak 
about  hypertro23hy  of  the  pharj-ugeal  tonsil  (adenoids),  and 
removal  of  this  tonsil  to  prevent  disturbances  which  may  be 
caused  by  its  hyj)ertrophy,  and  I  cannot  withhold  the 
opinion  that  we  are  apt  to  operate  too  much.  In  a  large 
majority  of  cases  the  increase  of  adenoid  tissue  is  only 
temporary  and  later  disappears,  or  the  development  of  the 
nasal  cavities  removes  any  disturbance  caused  by  the 
adenoid  growth,  and  one  often  sees  cases  in  which  no  good 
effect  has  resulted  from  the  operation,  or  the  old  symptoms 
reappear  after  a  time.  Whether  this  occurs  because  only 
part  of  the  pharyngeal  tonsil  has  been  removed  or  because 
the  adenoid  tissue  has  been  reformed  I  am  not  able  to  say, 
though  I  can  vouch  for  the  correctness  of  the  observations 
recorded  above.  In  these  cases  I  would  therefore  counsel 
patience  and  first  attempt  a  cure  with  astringent  lotions 
and  with  astringent  powders  applied  to  these  parts,  and 
have  recourse  to  operation  only  when  serious  obstruction  to 
nasal  respiration  urgently  demands  relief.  The  reflex 
theory  ascribes  a  number  of  nervous  phenomena  to  hyper- 
trophy of  the  pharyngeal  tonsil  and  overgrowth  of  the 
posterior  ends  of  the  turbinate  bones.  I  can  merely  state 
that  I  consider  these  assertions  somewhat  exaggerated,  and 
would  point  out  that  such  children  are  known  to  have  a 
predisposition  to  neurasthenia  ;  therefore  the  psychical 
effect  of  any  operation  upon  them  should  also  be  taken 
into  consideration. 

For  the  prevention  of  bronchitis  and  broncho-pneumonia 
at  this  period  of  life,  all  that  was  said  in  a  previous  para- 
graph about  these  affections  applies  also  to  this  period,  but 
"taking  cold  "  is  at  this  age  a  more  frequent  cause  of  these, 
and  requires  special  care.  In  previous  sections  we  have 
considered  how  far  it  is  230ssible  to  prevent  those  affections 
of  the  respiratory  tract  which  often  accompany  the  various 
infectious  diseases  and  seriously  affect  the  prognosis.  Once 
more  I  would  contrast  the  bad  influence  of  treatment  in  a 
hospital,  and  the  crowding  of   patients  into  badly  venti- 

494 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

lated  wards,  with  the  excellent  results  of  adequate  ventila- 
tion in  smaller  rooms,  and  the  frequent  change  of  the 
patient  from  room  to  room. 

Disorders  of  the  digestive  tract  do  not  occupy  so  im2Dortant 
a  position  in  early  childhood  as  they  did  in  infancy  ;  the 
chief  principles  which  must  now  guide  us  in  the  prevention 
of  these  diseases  are  to  give  a  suitable  diet  as  described 
above,  to  avoid  giving  meat  too  early,  to  exclude  bad  food 
or  very  indigestible  food,  and  to  prevent  the  overloading  of 
the  stomach  which  is  so  apt  to  occur  in  children  at  this  period. 
Plenty  of  vegetables  and  cooked  fruit  are  the  best  means 
against  the  obstinate  constipation  so  common  during  this 
period  of  life,  A  further  necessary  precaution  is  to  remove 
the  stones  from  fruit,  and  to  avoid  giving  any  food  which 
cannot  be  reduced  in  size  by  mastication  ;  such  articles  act 
as  foreign  bodies  in  the  intestines,  and  may  lodge  in  the 
vermiform  appendix  and  set  up  appendicitis.  Lastly, 
preventive  treatment  against  entozoa  must  be  considered. 
I  have  already  pointed  out  the  important  factor  of  playing 
with  earth,  of  eating  raw  or  imperfectly  cooked  meat,  and 
of  contact  with  domestic  animals.  I  have  only  to  draw 
attention  to  auto-infection  by  the  children  themselves,  who 
put  their  dirty  fingers  into  the  mouth  and  thus  convey 
the  ova  of  worms  into  the  body  where  the  ova  then 
develop ;  there  is  also  the  possibility  of  the  transference  of 
these  ova  from  child  to  child.  On  the  one  hand,  strict 
cleanliness  is  essential ;  on  the  other  hand,  caution  in  the 
intercourse  between  such  patients  and  their  playfellows. 
It  is  opportune  here  to  mention  the  common  custom  among 
the  public  of  giving  anthelmintics,  especially  preparations 
of  santonin,  as  a  preventive.  I  must  protest  against  this 
custom,  and  also  against  the  assumption  that  frequent  pick- 
ing of  the  nose  is  a  sure  sign  of  worms.  Anthelmintics 
should  only  be  used  when  worms  are  passed  or  their  eggs 
are  found  in  the  faeces,  and  then  only  by  medical  prescrip- 
tion. The  free  sale  of  anthelmintics  to  the  public  by 
chemists  I  consider  an  abuse. 

Among  diseases  of  the  genito-urinary   organs,  the  most 
important  is  vulvo-vaginitis,  which  may  occur  in  epidemic 

495 


THE  PREVENTION   OE  DISEASE 

form  aud  be  very  widespread  and  difficult  to  control, 
especially  in  hospitals  and  institutions.  In  a  former  para- 
graj)li  I  pointed  out  the  prophylactic  measures  to  be  taken 
against  spread  of  the  disorder,  and  against  the  risks  of 
infection  through  the  mother :  besides  these  infections 
through  accidental  contact,  we  must  bear  in  mind  too  at 
this  age  the  possibility  of  infection  of  the  genitals  of 
children  by  the  malpractices  of  individuals  suffering  from 
gonorrhoea,  There  is  a  possibility  of  spreading  the  disease 
by  baths  used  in  common.  Epstein  has  pointed  out  the 
dangers  of  public  baths  in  this  respect.  These  children 
may  also  spread  the  affection  at  school.  Preventive  treat- 
ment should  aim  at  removing  all  these  possible  sources  of 
infection.  These  patients  should  be  isolated,  care  being 
taken  that  their  linen  and  other  articles  used  by  them  are 
separately  washed ;  sleeping  with  strangers  should  be 
avoided,  the  children  should  be  kept  away  from  school ;  and 
girls  taken  into  hospital  should  be  examined,  and  all  suffer- 
ing from  vulvo- vaginitis  should  be  at  once  isolated.  It  is 
imj)ortant  too  occasionally  to  examine  the  secretion  micro- 
scopically so  that  the  nature  of  the  case  may  be  definitely 
diagnosed  and  the  duration  of  infection  ascertained. 

In  boys  balanitis  is  frequent  at  this  age  and  may  be 
prevented  by  cleanliness.  It  is  not  only  an  unpleasant 
condition,  which  causes  pain  and  urinary  difficulties  in  such 
boys,  but  observation  has  convinced  me  that  it  may  also  be 
the  cause  of  nocturnal  enuresis,  and  the  itching  associated 
with  the  condition  often  gives  rise  to  masturbation.  The 
preventive  measures  are  obvious  :  the  glans  should  be  fre- 
quently washed,  some  simple  ointment  may  be  applied,  and 
any  phimosis  treated. 

The  most  important  of  the  diseases  peculiar  to  this  period 
of  childhood  have  now  been  mentioned,  in  so  far  as  their 
course  can  be  influenced  by  preventive  measures,  and  I 
now  proceed  to  describe 

THE  PEEVENTIVE    TEEATMENT    OF    DISEASES  OF  LATER 

CHILDHOOD 

To  prevent  repetition  I  shall  leave  out  of  consideration 

496 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDEEN 

those  diseases  which  in  their  invasion,  coiu'se  and  preven- 
tion cannot  be  separated  from  those  of  early  childhood. 
Nevertheless  aU  the  principles  previously  laid  down  must  be 
borne  in  mind,  and  they  can  be  carried  out  more  easily  now 
that  the  child  is  more  intelligent  and  self  dependent.  These 
diseases  are  influenced  to  some  extent  by  school  life  and 
work,  the  want  of  exercise  and  fresh  air  necessitated  by  the 
increased  demands  made  by  education,  and  further  by  a 
new  factor,  "•  nervous  contagion,"  which  now  appears  and 
demands  our  attention  that  it  may  be  adequately  treated 
and  prevented.  The  physician  and  the  teacher  should 
work  hand  in  hand,  but  the  physician  is  unfortunately 
often  unable  to  act  effectively,  and  the  requirements  of 
education  and  of  hygiene  are  often  opposed,  and  the  influ- 
ence of  the  physician  in  the  school  is  less  than  could  be 
wished.  But  so  far  as  it  is  possible  efforts  should  be  made 
to  prevent  mental  overstrain  and  to  check  the  injurious 
mental  and  physical  effects  which  are  attributable  to  educa- 
tion. Prophylactic  measures  to  ensure  the  normal  healthy 
development  of  children  are  as  important  as  the  prevention 
of  infective  diseases  and  of  digestive,  respiratory  and 
similar  disorders.  The  question  can  be  treated  only  very 
briefly  here,  and  for  details  I  must  refer  the  reader  to  works 
on  school  hygiene,  but  for  the  sake  of  completeness  they 
cannot  be  altogether  omitted  in  this  book. 

Apart  from  spreading  infectious  disease,  school  life  may 
exert  a  bad  influence  in  various  ways  upon  the  physical 
and  mental  development  of  the  child.  The  danger  is  less 
in  the  lower  classes,  the  short  school  hours,  the  small  amount 
of  homework,  the  fact  that  reading  and  writing  are  only 
being  begun  and  the  innate  restlessness  of  the  child  prevent 
these  injurious  effects  from  appearing.  But  in  the  later 
years,  even  at  a  primary  school,  there  are  too  many  hours 
spent  in  sitting  at  school,  and  too  much  close  work  for  the 
growing  eye,  its  homework  keeps  the  child  too  long  at 
the  table,  and  its  need  for  physical  movement  and  fresh  air 
are  not  sufficiently  regarded.  xAdd  to  this  the  ill  effects  of 
insufficient  light,  the  overcrowding  of  the  schoolroom,  the 
faulty  postures  in  sitting,  the  bad  print  of  schoolbooks,  and 

497  KK 


THE   PREVENTION  OF  DISEASE 

the  incorrect  position  in  writing,  and  we  liave  a  number  of 
disturbing  causes  wHcJi  must  be  briefly  considered.  Myopia 
is  very  common  in  sclioolcliildren,  and  increases  as  the 
child  goes  from  class  to  class :  it  is  caused  by  an  excessive 
effort  at  accommodation,  and  it  is  also  harmful  for  the  eyes 
and  therefore  it  should  be  prevented  by  appropriate  means. 
Among  these  may  be  mentioned  good  illumination  for  every 
seat,  suitable  blackboards  which  do  not  reflect  light  and  so 
strain  the  eyes,  well  printed  schoolbooks,  suitable  hand- 
writing upright  and  large,  a  correct  length  of  the  lines  and 
distance  between  the  lines,  and  the  avoidance  of  artificial 
light  which  strains  the  eyes.  These  are  to  some  extent 
already  attained  in  schools  with  modern  equipment  and  with 
specially  drawn-up  rules ;  but  in  the  home  these  matters  do 
not  yet  receive  proper  attention,  and  the  physician  should 
see  that  at  home  too  the  child  has  an  apj^ropriate  place  in 
which  to  work,  and  that  it  is  not  occupied  too  long  with 
book  work. 

Another  injurious  effect  resulting  from  school  and  home 
education  is  curvature  of  the  spine,  caused  by  badly  con- 
structed seats,  together  with  a  wrong  posture  in  writing 
and  too  long  continued  writing.  Though  in  most  places 
nowadays  care  is  taken  to  place  a  child  at  a  suitable  distance 
and  on  a  bench  which  is  adapted  to  his  size,  and  the  upright 
style  of  handwriting  now  taught  tends  to  make  the  child 
sit  straight,  yet  the  long  hours  which  a  child  is  kept  at 
writing  undoes  a  part  of  the  good  thus  accomplished,  and 
this  is  made  still  worse  by  the  large  amount  of  homework 
which  the  children  have  to  do,  generally  on  badly  con- 
structed tables  and  in  bad  postures  and  in  insufficient  light. 
One  should  therefore  insist  u]pon  the  child  having  a  suitable 
desk  at  home,  which  is  placed  so  as  to  be  adequately  supplied 
with  light,  and  one  should  watch  the  number  of  hours  given 
to  homework,  as  the  physician  is  the  best  judge  as  to  the 
amount  of  mental  work  which  a  given  child  can  do  without 
injury  to  itself. 

School  headaches,  anaemia  and  epistaxis  are  caused  by 
remaining  long  in  closed  and  often  overcrowded  rooms  and 
by  the  constant  exercise  of  mental  energies  along  this  one 

498 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

channel  only,  and  they  are  often  accompanied  by  loss  of 
appetite  and  by  insomnia.  In  this  conflict  between  the 
requirements  of  education  and  of  physical  health  it  is  often 
very  difiicult  to  convince  parents  that  the  latter  is  more 
important,  and  they  point  out  that  the  child  will  be  out- 
stripped by  its  competitors,  Nevertheless  in  a  few  bad 
cases  I  have  insisted  upon  a  whole  year  of  school  life  being 
given  up,  and  have  employed  this  solely  in  building  up  the 
physical  health  which  had  been  neglected,  and  I  have  never 
had  cause  to  regret  this  course.  It  is  the  physician's  duty 
to  see  that  the  child's  hours  of  sleep  are  not  curtailed,  and 
all  work  after  supper  should  be  forbidden.  When  the 
intellectual  capacity  and  ability  of  the  child  are  insufficient 
to  enable  it  to  do  the  homework  during  the  daytime,  the 
work  must  be  left  undone,  and  it  may  be  necessary  to  inter- 
rupt the  education  for  a  time.  Out-of-door  exercise, 
gymnastics  and  field  games  are  the  most  effectual  antidote 
to  the  ill  effects  of  much  sedentary  work.  During  the  few 
hours  given  to  recreation  the  mind  should  be  allowed  to 
rest,  exciting  books,  theatres,  and  such  amusements  should 
be  forbidden.  The  child's  walks  out  of  doors  will  supply 
it  with  new  and  fresh  experiences.  Unfortunately,  especi- 
ally in  the  higher  schools  as  already  said,  we  are  scarcely 
able  to  make  our  influence  felt  against  this  common  over- 
strain of  children's  minds,  but  nevertheless  we  must  exer- 
cise a  careful  supervision  and  must  put  a  veto  upon  this 
education  of  a  child  when  we  see  that  its  health  will  be 
seriously  injured  thereby. 

As  regards  the  diet  of  children  at  this  age  when  they 
dine  with  adults,  all  indigestible  food  must  be  avoided,  the 
food  should  be  simple,  all  alcoholic  drinks  should  be 
excluded  as  they  only  tend  still  further  to  increase  the 
cerebral  hyperaemia  already  existing.  The  child  should  go 
to  bed  early,  and  should  be  kept  from  the  social  entertain- 
ments and  recreations  of  adults. 

Hysteria,  of  which  we  see  many  serious  cases  even  at  this 
early  age,  is  steadily  increasing.  The  disease  is  caused  partly 
by  the  great  demands  of  school  life,  partly  by  our  modern 
manner  of  life.     Its  preventive  treatment  is  in  education, 

499 


THE  PREVENTION  OE  DISEASE 

and  it  should  be  remembered  that  its  characteristic  mani- 
festations are  often  passed  on  to  susceptible  companions  of 
the  same  age,  and  in  this  way  the  most  remarkable  school 
epidemics  arise  by  ''  nervous  contagion."  It  is  therefore 
advisable  to  keep  such  children  from  school. 

The  same  remarks  apply  to  chorea,  which  is  so  common 
at  this  age.  Teachers  ought  to  be  more  familiar  with  the 
initial  stages  of  chorea  than  they  generally  are ;  they 
would  then  cease  to  blame  and  punish  such  children  and 
aggravate  the  disease.  Here  again  the  need  for  school 
physicians  is  evident. 

Night  terror  requires  certain  preventive  measures  :  rest 
of  the  brain  for  some  time  before  going  to  sleep,  and  the 
avoidance  of  mental  work,  of  exciting  books,  or  tales  which 
stimulate  the  imagination  of  the  child,  are  the  chief  points  to 
be  observed.  From  the  standpoint  of  aetiology  much  more 
importance  should  I  think  be  attached  to  such  symptoms 
when  associated  with  a  weak  constitution,  anaemia  and  over- 
strain, than  to  the  hypertrophy  of  lymphatic  tissue  in  the 
pharynx  or  to  nasal  affections. 

Finally  I  would  add  that  the  holidays  of  these  children, 
short  as  they  are,  should  be  used  to  remove  injurious  effects 
which  have  arisen  during  the  school  year  and  to  strengthen 
the  body  to  meet  the  new  demands  which  will  be  made 
upon  it.  All  mental  work  should  therefore  be  forbidden 
during  the  holidays,  and  all  that  is  possible  should  be  done 
to  improve  the  physical  health  of  these  children.  For  this 
purpose  they  should  have  moderate  exercise  and  plenty  of 
nourishing  food,  but  should  not  be  taken  for  long  tiring 
walks  or  mountain  tours,  as  so  often  happens  when  fathers 
take  with  them  their  half  grown  up  children. 

I  come  now  to  the  last  part  of  my  subject,  to  the  so- 
called 

PKOPHYLAXIS  IN  TEEATMENT 

This  section  concerns  us  physicians  most  intimately,  and 
I  would  head  it  with  "wo/^  nocere^  The  great  progress  made 
in  therapeutics  during  the  last  decade  is  reason  enough 
to  make   us  hold   views  other  than  the  negative  ones  of 

500 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

former  times  ;  on  the  other  hand  we  must  guard  against 
going  to  the  other  extreme  and  make  use  of  measures  of 
which  we  are  not  quite  certain  and  which  are  not  altogether 
free  from  danger.  We  should  keep  clearly  before  us  the 
measures  and  modes  of  treatment  which  are  best  adapted 
for  any  particular  period  and  those  which  should  be  avoided. 
And  lastly,  the  children  entrusted  to  our  medical  care, 
whether  in  private  life  or  in  hospitals,  must  not  be  regarded 
as  subjects  for  doubtful  experiments.  "We  should  always 
well  consider  whether  the  satisfying  of  scientific  curiosity 
may  be  of  disadvantage  to  the  sick  child.  These  are  the 
limits  within  which  so-called  curative  prophylaxis  should 
work. 

To  give  a  few  examples.  Opium  and  its  derivatives, 
morphine,  codeine,  belladonna  and  hyoscyamus,  should  be 
avoided  during  the  first  year  of  life,  since  even  after  very 
small  doses  serious  symptoms  may  appear.  In  the  treat- 
ment of  gastro-intestinal  disorders  we  can  obtain  much 
better  results  by  mechanically  emptying  the  digestive  tract 
and  by  appropriate  dietary  regulations  than  by  internal 
remedies,  and  these  should  therefore  be  restricted  to  the 
utmost.  Infants  seem  to  be  particularly  susceptible  to 
certain  drugs,  such  as  potassium  chlorate  and  naphthalin, 
while  they  tolerate  relatively  large  doses  of  other  drugs, 
such  as  the  expectorants  ipecacuanha  and  senega.  Salicylic 
acid  and  salicylates  are  not  always  tolerated  ;  mercury  and 
potassium  iodide,  on  the  other  hand,  when  properly  given, 
leave  no  unpleasant  after-effects.  Much  depends  too  upon 
the  mode  of  its  exhibition.  With  many  drugs  the  most 
effectual  and  harmless  method  is  to  administer  the  drug 
internally  in  the  liquid  form,  and  I  may  mention,  besides 
those  already  referred  to,  the  various  drugs  used  in  digestive 
disorders,  such  as  hydrochloric  acid,  lactic  acid,  sodium  ben- 
zoate,  magnesium  benzoate,  and  bismuth  salicylate.  With 
other  drugs  cutaneous  application  is  best :  for  instance, 
salicylic  acid  and  especially  mercury,  which  is  so  well 
tolerated  when  thus  administered,  while  it  readily  sets  up 
diarrhoea  when  administered  internally.  I  would  also 
strongly  recommend  a  trial  of  the  new  "  merkolint "  method 

501 


THE  PREVENTION   OF  DISEASE 

for  hereditary  syphilis  in  infants.  Subcutaneous  injection, 
very  useful  in  later  childhood,  is  not  suitable  during  the 
first  year  of  life,  and  abscesses  readily  form  at  the  site  of 
the  puncture.  Caution  must  be  observed  too  in  the  use  of 
antiseptics.  Experience  has  shown  that  carbolic  acid  is 
very  badly  tolerated  by  infants,  that  iodoform  sometimes 
gives  rise  to  skin  irritation,  while  corrosive  sublimate  in 
weak  solution,  not  over  two  parts  in  1,000,  can  be  used 
with  perfect  safety.  I  altogether  refrain  from  giving 
internal  antipyretic  remedies  during  childhood,  at  least  in 
the  way  formerly  practised.  On  the  other  hand  I  can 
strongly  recommend  lukewarm  baths  and  wet  compresses, 
not  so  much  because  of  their  antipyretic  power  as  because 
of  their  soothing  effect.  A  cold  bath  may  readily  cause 
collapse,  and  should  be  watched  by  the  physician.  I  avoid 
it  altogether,  and  have  elsewhere  stated  my  reasons.  Even 
wet  compresses  may  do  harm,  either  by  giving  rise  to 
eczema  or  by  causing  exfoliation  of  the  epidermis  as  I  have 
seen  in  delicate  children.  A  new  drug  should  be  used  with 
great  caution,  and  at  first  only  in  smaller  doses  than 
recommended.  Enthusiasm  combined  with  a  lack  of  judg- 
ment which  after  a  few  hasty  and  insufficient  observations 
lauds  the  beneficial  effects  of  new  preparations  should  warn 
us  to  be  cautious.  For  washing  out  the  stomach  and 
bowel  the  temperature  of  the  liquid  should  be  exactly 
taken ;  too  much  fluid  and  too  rapid  injection  of  it  should 
be  avoided.  Personal  experience  has  proved  to  me  that  the 
addition  of  resorcin  and  tannin  is  best  avoided.  A  further 
precautionary  method  to  be  observed  in  infancy  is  to  give 
the  drug  in  very  small  doses  and  to  get  the  cumulative 
effect  of  it,  and  whenever  possible  to  select  the  liquid  form 
of  the  drug,  and  to  avoid  during  the  first  months  of  life  any 
addition  of  material  capable  of  undergoing  fermentation, 
such  as  the  very  favourite  syrups. 

In  later  childhood  too  it  is  best  to  avoid  treatment  of 
fever  by  drugs,  which  after  all  can  only  modify  an  inci- 
dental symptom  of  the  infection,  but  cannot  in  any  way 
influence  the  course  of  the  disease  ;  rather  indeed,  when 
given  in  large  doses  and  when  badly  tolerated,  it  will  give 

502 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

rise  to  serious  cardiac  symptoms.  Among  antipyretics 
antifebrin  and  antipyrin  in  large  doses  are  often  not  ■well 
borne,  but  cause  vomiting  or  rashes.  Quinine  too  cannot 
be  extensively  used  because  of  its  taste  and  the  difficulty 
of  disguising  it,  and  the  administration  of  these  drugs  in 
pill  or  wafer  is  only  possible  for  older  children.  The  most 
convenient  antipyretic  is  phenacetin,  which  is  almost  taste- 
less, and  small  doses  of  it,  one  to  three  grains,  are 
sufficient  to  bring  down  the  temperature  for  a  few  hours 
without  unpleasant  after  effects.  Of  the  external  methods 
for  reducing  temperature  during  the  second  period  of  child- 
hood I  prefer  wet  packs  and  lukewarm  baths,  while  in 
later  childhood  I  use  a  bath  which  is  gradually  cooled  down 
or  a  cold  douche.  But  here  too  moderation  is  required. 
The  slight  reaction  of  most  children  after  high  tempera- 
tures, together  with  the  fact  that  the  severest  infections 
often  run  a  course  with  but  slight  rise  of  temperature, 
considerably  limit  these  indications  and  only  justify  us  in 
adopting  these  measures  when  there  is  hyperpyrexia, 
serious  implication  of  the  sensorium  or  great  nervous 
unrest. 

I  have  already  protested  against  the  casual  use  of  worm 
powders,  and  I  would  here  caution  against  the  "cures"  for 
tapeworm,  especially  as  the  greater  number  of  cases  of 
poisoning  by  Filix  mas  are  met  with  in  childhood.  Such 
drugs  should  only  be  administered  by  the  direction  of  a 
physician  who  lives  near  the  patient. 

Anaesthesia  by  chloroform  is  often  induced  for  diagnostic 
purposes  or  to  remove  an  excitable  condition  in  restless 
children,  and  I  cannot  too  strongly  protest  against  this 
course.  Only  when  there  is  some  vital  reason  for  inducing 
anaesthesia,  such  as  the  diagnosis  of  a  tumour  or  appendi- 
citis, does  it  appear  to  me  justifiable ;  in  other  cases  I 
consider  its  use  an  unpardonable  thoughtlessness  which 
may  have  serious  results. 

Indeed  the  use  of  such  heroic  methods  of  examination  as 
have  been  introduced  into  hospitals  of  late  years  to  clear  up 
certain  scientific  contentions  should  be  restricted  within 
wise  limits,  and  experiments  upon  human  beings,  especially 

503 


THE  PREVENTION   OF   DISEASE 

upon  cliildren  wliose  consent  cannot  be  asked,  should  be 
narrowed  down  to  the  utmost.  Among  these  methods  are 
the  withdrawal  of  large  quantities  of  blood  for  various 
didactic  reasons  and  dieting  methods  by  which  healthy- 
young  children  are  supplied  with  insufficient  food  for  days. 
No  permanent  injurious  results  have  been  observed,  or  at 
least  they  have  not  been  recorded,  fco  follow  this  experi- 
mental work,  but  it  scarcely  seems  to  me  wise  to  wait  till 
then.  Our  experience  in  the  domain  of  the  conveyance  of 
syphilis  and  of  the  inoculation  of  healthy  individuals 
with  gonococci  shows  plainly  enough  that  the  utility  of 
such  methods  is  not  j)roportionate  to  the  dangers  incurred. 

Neither  can  I  speak  enthusiastically  about  lumbar 
puncture,  which  has  become  a  favourite  method  during 
recent  years.  It  is  certainly  a  valuable  addition  to  our 
knowledge  to  have  gained  information  in  this  way  about 
the  pressure  within  the  skull  under  normal  and  under 
pathological  conditions,  and  the  amount  of  albumen  present 
in  cerebro-spinal  fluid  and  of  the  bacteria,  yet  I  cannot 
maintain  that  the  diagnosis  of  the  various  inflammations 
which  affect  the  central  nervous  system  has  been  furthered 
by  this  method  of  research.  And  as  to  the  therapeutic 
value  of  this  method  we  feel  a  little  sceptical  about  the 
assertions  of  its  enthusiastic  advocates.  At  any  rate  when 
we  consider  the  risks  of  a  possible  infection  of  the  spinal 
canal  and  other  possible  evil  results,  it  would  seem  essential 
that  this  method  should  only  be  carried  out  in  hospitals 
where  there  is  adequate  assistance,  and  that  the  physician 
should  send  into  hospital  every  child  who  is  to  be  treated 
by  this  method. 

Recently  too  the  question  of  intubation  in  private 
practice  has  been  raised,  and  I  would  take  this  opportunity 
of  saying  that  this  course  can  only  be  regarded  as  justifi- 
able and  free  from  serious  risk  when  it  is  possible  to 
arrange  for  continuous  and  adequate  medical  aid  for  the 
child  during  the  first  few  days. 

I  will  refrain  from  further  detail,  as  I  wished  only  to  point 
to  the  directions  in  which  caution  should  be  exercised  by 
physicians  in  the  treatment  of  children  entrusted  to  their 

504 


THE  PREVENTION  OF  THE  DISEASES  OF  CHILDREN 

care,  and  did  not  intend  to  discuss  individually  every 
method  and  every  drug  employed.  With  increasing  years 
and  experience  we  become  more  moderate,  and  learn  to  avoid 
certain  therapeutic  measures  which  formerly,  with  the 
zeal  and  sanguine  nature  of  youth,  infatuated  us.  With 
this  I  will  end  my  remarks,  which  have  already  taken  up 
almost  too  much  space,  but  my  apology  for  the  length  of 
this  section  is  the  importance  of  preventive  measures  in  the 
most  susceptible  period  of  life,  when  they  are  most  service- 
able in  the  development,  education,  hygiene  and  treatment 
of  children.  And  though  there  are  many  omissions  in  these 
pages,  yet  I  have  I  think  considered  all  the  means  by  which 
it  is  possible  effectually  to  prevent  the  diseases  of  childhood. 
I  hope  that  the  study  of  aetiology  will  soon  give  us  a  deeper 
insight  into  those  pathological  processes  which  are  still 
unexplained,  and  will  enable  us  to  meet  them  with  greater 
knowledge  and  better  results  than  hitherto,  and  thus  prevent 
disease  and  the  spread  of  disease,  and  secure  for  the  rising 
generation  the  conditions  of  life  required  for  their  robust 
and  normal  development. 


505 


*^<u 


